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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602542
Report Date: 02/21/2023
Date Signed: 02/21/2023 02:59:29 PM

Document Has Been Signed on 02/21/2023 02:59 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:
02/21/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Administrator Neisha Brown.TIME COMPLETED:
03:15 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-continuation visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA spoke with facility staff to conduct the covid-19 screener questionnaire and was informed the facility is free of Covid-19. LPA was met facility staff and was allowed entry into the facility

LPA Shirley reviewed infection control Care tool with staff Neisha Brown.

No deficiencies cited during todays visit.

Exit interview conducted. A copy if this is being furnished to facility representative.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2023
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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