198602542-2-5-2025-11-AS-FSHY-DDLVE5-20250205152145

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602542
Report Date: 02/05/2025
Date Signed: 02/05/2025 05:54:34 PM

Document Has Been Signed on 02/05/2025 05:54 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 CARE		FACILITY NUMBER:	198602542
ADMINISTRATOR/ DIRECTOR:	HARRISON, HONORA		FACILITY TYPE:	735
ADDRESS:	2030 W 144 STREET		TELEPHONE:	(310) 515-4757
CITY:	GARDENA	STATE: CA	ZIP CODE:	90249
CAPACITY: 4		CENSUS: 3	DATE:	02/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Joan Forbes, Staff		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

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On 2/5/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with the Administrator, Zoe Clark and explained the purpose of today’s visit. The facility is licensed to serve adult developmentally disabled residents ages 18 thru 59 years old.

LPA reviewed all resident files and found that they did contain all required documents. LPA reviewed six (3) staff files and found they did contain all required documents, training, and certification. LPA Shirley reviewed all residents MAR and medications. During file review, LPA observed the liability and surety bond.

LPA Felisa and staff, Joan toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (3) client bedrooms, (2) bathrooms, living room, kitchen, and dining area. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedrooms 1-3 are occupied by residents and contain the mandated furniture. LPA observed all rooms to have the required furniture including a bed, dresser(s), and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley and Joan toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored. The medications were locked and stored in the cabinet located in the kitchen. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods.

Con'd on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 198602542
	VISIT DATE: 02/05/2025

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The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility. This facility is in good repair. The water delivered at 118.1 F.

LPA Shirley and Joan walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher located in the living room. The backyard is clean and clear of obstructions and hazards, and there are no bodies of water present.

An exit interview was conducted, and a copy of this report was signed by and given to the Administrator, Zoe Clark.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

LIC809 (FAS) - (06/04)

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