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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602256
Report Date: 07/21/2024
Date Signed: 07/21/2024 02:57:36 PM

Document Has Been Signed on 07/21/2024 02:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:GOSSETT RESIDENTIAL SERVICES INC #1FACILITY NUMBER:
198602256
ADMINISTRATOR/
DIRECTOR:		GOSSETT, DWIGHT LFACILITY TYPE:
735
ADDRESS:9027 SOUTH HALLDALE AVENUETELEPHONE:
(323) 359-9805
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 6CENSUS: 2DATE:
07/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:22 PM
MET WITH:Gossett Dwight lTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 07/21/2024, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced required 1- year visit using the new CARE Inspection Tool. LPA Richard met with the Facility Manager Dwight Gossett and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently two (2) South Central Los Angeles Regional Center (SCLARC) consumers in placement. The facility's annual fees are current.

The following Domain will be observed and reviewed: Infection Control Practices "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

The facility is a single-family home located in a residential neighborhood. LPA Richard and Facility Manager Gossett toured the facility which consisted of the following: Living room, dining area, kitchen, 4 bedrooms, 1 ½ bathroom, laundry area, shaded area, indoor/outdoor activity areas, and a detached garage. The front and back yard landscape is in good condition at the time of the visit.
There is a hot tub in the backyard that is drained and has a cover. LPA observed sufficient seven day non-perishable and two day perishable food supplies. The hot water temperature was measured at 105.1F degrees Fahrenheit. Which is within the required range of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke detectors are current and in compliance with fire safety. First aid kit was checked and is complete. Sufficient lighting in hallways and passageways. The administrator certificate expired 02/22/2026.

There were no deficiencies cited. Exit interview conducted a copy of the report was provided to Mr. Gossett. The Facility Manager.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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