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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602366
Report Date: 11/16/2023
Date Signed: 11/16/2023 12:45:19 PM

Document Has Been Signed on 11/16/2023 12:45 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CN HOME 1FACILITY NUMBER:
198602366
ADMINISTRATOR:MANBIR SONDFACILITY TYPE:
735
ADDRESS:1750 ARLINGTON AVETELEPHONE:
(310) 612-0978
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 4CENSUS: 4DATE:
11/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Mae Torres, Administrator IITIME COMPLETED:
12:50 PM
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On 11/16/23, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator II Mae Torres. LPA explained the purpose of today’s visit. The facility is licensed to operate for four (4) non-ambulatory clients 18 through 59 years of age. The clients are Harbor Regional Center consumers. A total of 4 clients are currently residing in this facility, 4 out of 4 clients are non-ambulatory. A total of 4 staff and 2 clients were present during this inspection.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: four (4) client's rooms, three (3) bathrooms, a living area, dining area, kitchen, and outside area.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 105.3 - 109 degrees F.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. The last fire drill was conducted on 10/19/23. The facility has a working landline telephone. The facility has a current Certificate of Liability Insurance.

Continue to LIC809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CN HOME 1
FACILITY NUMBER: 198602366
VISIT DATE: 11/16/2023
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LPA observed that Medications were safe, locked and inaccessible. Medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. First aid kit is fully stocked with manual.

Five (5) staff records were reviewed, 5 out of 5 staff records had required criminal record clearances. Two staff were interviewed.

Four (4) client records were reviewed and, 4 out of 4 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and Needs & Services Plans. Two (2) client Medication Records Administration (MAR) was reviewed. One client was interviewed.

No deficiencies cited.

A copy of this report were discussed and left with Administrator II, Mae Torres.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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