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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602542
Report Date: 02/10/2023
Date Signed: 02/10/2023 03:33:20 PM

Document Has Been Signed on 02/10/2023 03:33 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CHELSEA RESIDENTIAL CAREFACILITY NUMBER:
198602542
ADMINISTRATOR:HARRISON, HONORAFACILITY TYPE:
735
ADDRESS:2030 W 144 STREETTELEPHONE:
(310) 515-4757
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 4CENSUS: 3DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Administrator Zoie ClarkeTIME COMPLETED:
03:40 PM
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On 2/10/2023, Licensing Program Analyst (LPA) Felisa Shirley and Licensing Program Manager(LPM) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA spoke with Staff Neisha Brown to conduct the covid-19 screener questionnaire and was informed the facility is free of Covid-19. LPA was met by Administrator Zoie Clarke and explained the purpose of today’s visit is the annual inspection visit concentrating on Infection Control Measure and was allowed entry into the facility. The facility is an ARF licensed for four (4) ambulatory client.

The facility is a single-story, 3-bedrooms, 2-bathroom one office home located in a residential neighborhood. It consists of the following: facility which included: Living room, dining area, kitchen, family room, laundry area, attached garage, shaded outdoor activity areas.

LPA and staff toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were clean and operational.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. The kitchen was inspected and there is a 2-day supply of perishable and a 7-day supply of non-perishable food available, maintained properly. One fully charged fire extinguishers was found in dining room.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, a 30-day supply of Personal Protective Equipment (PPE) is available and sign in and out logs for visitors and staff are present in the facility.

Due to time constraints, the inspection will be completed at a later date.

An exit interview was conducted, and a copy of this report was provided to Zoie Clarke Administrator.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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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