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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602879
Report Date: 12/02/2023
Date Signed: 12/02/2023 04:16:50 PM

Document Has Been Signed on 12/02/2023 04:16 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SOUTH BAY CIRCLE OF FRIENDS INCFACILITY NUMBER:
198602879
ADMINISTRATOR:QUAN, MARIAFACILITY TYPE:
735
ADDRESS:18509 S ILLINOIS CTTELEPHONE:
(310) 715-1828
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 5CENSUS: 4DATE:
12/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:SUYONO WONGTIME COMPLETED:
04:30 PM
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On 12/02/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with staff Calvin Fortune and later joined with Administrator Suyono wong and explained the purpose of today’s visit. The facility is licensed to operate for five (5) ambulatory clients between the ages of 18 through 59. Currently, the facility home has four (4) clients.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client rooms, two (2) bathrooms, two (2) living areas, dining area, laundry in garage, kitchen, and outside shaded patio area.

LPA Richard and staff Fortune toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature measured between 109.7F to 108.3F in both bathrooms. A comfortable temperature of 74 degrees was maintained in the facility.

LPA Richard observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available. There is one (1) fire extinguisher fully charged in the kitchen. Smoke detectors and carbon monoxide were operable. A reviewed of Medication Records Administration (MAR) and observed to be maintained in order and accurate.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SOUTH BAY CIRCLE OF FRIENDS INC
FACILITY NUMBER: 198602879
VISIT DATE: 12/02/2023
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The last fire drill was on 11/06/2023.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Administrator Suyono wong
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023
LIC809 (FAS) - (06/04)
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