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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602559
Report Date: 12/18/2024
Date Signed: 12/18/2024 01:46:11 PM

Document Has Been Signed on 12/18/2024 01:46 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:GARTH HOMEFACILITY NUMBER:
198602559
ADMINISTRATOR/
DIRECTOR:		WEINGARTEN, GOLDAFACILITY TYPE:
734
ADDRESS:5505 S GARTH AVETELEPHONE:
(650) 238-4987
CITY:LOS ANGELESSTATE: CAZIP CODE:
90056
CAPACITY: 5CENSUS: 5DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:11 AM
MET WITH:Administrator Golda WeingartenTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 12/18/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Golda Weingarten as the purpose of the visit was explained. The facility is licensed to serve 5 non-ambulatory adults of which 5 may be bedridden. Clients are linked to the Westside and Lanterman regional center.

The facility is a single-story structure located in a residential neighborhood and consists of the following: 5 client bedrooms, 2 1/2 bathrooms, office space, dining area, living room, kitchen, and a garage. 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 3 staff records, 3 client records, and a review of 3 medications. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The disaster drills was conducted on 12/4/24, fire extinguisher fully charged, carbon monoxide and smoke detectors are operational.

Citation documented on 809D page

Exit interview conducted, appeal rights explained, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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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Document Has Been Signed on 12/18/2024 01:46 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 12/18/2024 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GARTH HOME
FACILITY NUMBER: 198602559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f)

This requirement is not met as evidenced by:


Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as LPA Villegas did not observe an association to facility #198602559 in Guardian for staff #1 which poses an immediate safety risk to persons in care.
POC Due Date: 12/19/2024
Plan of Correction
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The Administrator immediately associated Staff #1 to facility #198602559.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


LIC809 (FAS) - (06/04)
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