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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602366
Report Date: 08/23/2024
Date Signed: 08/23/2024 11:16:56 AM

Document Has Been Signed on 08/23/2024 11:16 AM - 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:CN HOME 1FACILITY NUMBER:
198602366
ADMINISTRATOR/
DIRECTOR:
MANBIR SONDFACILITY TYPE:
735
ADDRESS:1750 ARLINGTON AVETELEPHONE:
(310) 612-0978
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 4CENSUS: 4DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Melinda BlackTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 08/23/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Melinda Black as the purpose of the visit was explained. The facility is licensed to serve (4) develop disabled clients ages 18-59. Clients are linked to the Harbor regional center. Current facility census is 4. Liability insurance with expiration date of 04/24/25 was observed. Facility fees info with pin was provided.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: (4) client's rooms all on the first floor, (3) bathrooms, a living area, dining area, kitchen, laundry room, linen closet, a garden and a shaded seating area. Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 2 staff records, 2 client records, and 2 medication administration records, and 2 P&I ledgers, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 07/12/24, fire extinguisher fully charged, carbon monoxide and smoke detectors were observed and operational. During today's visit no citations were given.

Exit interview conducted with Melinda Black, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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