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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602542
Report Date: 02/08/2024
Date Signed: 02/08/2024 02:52:18 PM

Document Has Been Signed on 02/08/2024 02:52 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: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: 2DATE:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:Zoie Clark, AdministratorTIME COMPLETED:
03:30 PM
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On 2/8/2024, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was met by Administrator Zoie Clarke and explained the purpose of today’s visit is the annual inspection. The facility is an ARF licensed for four (4) ambulatory clients.

The facility is a single-story, 3-bedrooms, 2-bathroom, with office home located in a residential neighborhood. It consists of the following: 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.

The kitchen was inspected and there is a 3-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.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit.

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: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2024
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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