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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602879
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:05:01 PM

Document Has Been Signed on 07/03/2024 04:05 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/
DIRECTOR:		QUAN, MARIAFACILITY TYPE:
735
ADDRESS:18509 S ILLINOIS CTTELEPHONE:
(310) 715-1828
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 5CENSUS: 4DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Suyono 'John' WongTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 07/03/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Staff, Calvin Fortune, and the purpose of today was explained. We were joined by Program Director, Hai Nguyen, and Administrator, Suyono ‘John’ Wong. The facility is licensed to serve five (5) ambulatory clients ages 18 through 59. Currently the facility has four (4) clients that were at day program during the time of visit.
Physical Plant/Structure The facility is a single-story home in a residential neighborhood. It consists of four (4) bedrooms, two (2) bathrooms, two (2) living areas, dining room, kitchen, attached garage, and an outside shaded patio. LPA observed the patio had a table and chairs available for client use. LPA observed all walkways around the home to be clean, clear, and free of debris, hazards, and obstructions. LPA did not observe any bodies of water on the premises.
Bedrooms LPA inspected all rooms and found them to be clean and in good repair. LPA observed the rooms have the required furniture including a bed, dresser, nightstand, chair, and storage space for personal belongings. LPA observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an additional supply of linens stored in a

Continued on LIC809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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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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: 07/03/2024
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cabinet and additional linens are stored in Client rooms in a cupboard above the closet. All linens and mattress were observed in good condition. All rooms were observed to have ample lighting.
Bathrooms LPA observed all bathrooms to be operable and within Title 22 regulations. The toilets, faucets, and showers work properly. The bathrooms were observed clean. The showers were observed with secured safety handrails and nonskid mats or material. The showers were observed to be free of mold and mildew. LPA observed storage space for residents’ hygiene products. LPA observed an ample supply of towels and hygiene products available for residents. The water temperature measured 109.2-degrees and 106.5-degrees Fahrenheit.
Kitchen LPA observed the kitchen to be clean and sanitary. LPA observed all appliances to be operable. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All foods were observed properly labeled, packaged, and stored. LPA observed knives and sharps to be secured in a locked drawer in the kitchen and are inaccessible to clients. LPA observed a sample menu posted in the pantry. LPA observed cleaning supplies to be secured in a cabinet under the kitchen sink and are inaccessible to clients. The water temperature measured 106.2-degrees Fahrenheit.
Common Rooms One living room had two couches and a swing chair to accommodate Clients. Living room two has two (2) couches, a desk with a computer, and a bookcase with games and activities. The dining room has a table

Continued on LIC809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
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: 07/03/2024
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and chairs to accommodate all clients. The facility was kept at a comfortable temperature. The facility was observed appropriately furnished during the time of visit. All walkways and hallways in the home were observed clean, clear, and free of hazards and obstructions. LPA observed all rooms and hallways to have ample lighting. LPA observed a screened fireplace that is inaccessible to clients.
File Review LPA reviewed the files for four (4) clients and found they contained the required documents. LPA interviewed one (1) client who is happy with the care and services received at the facility. LPA reviewed the Administrator file, and two (2) staff files and found they contained the required documents, certification, and training. LPA interviewed one (1) staff who were able to answer questions regarding resident care, policies, procedures, and resident personal rights. LPA observed the administrator’s Administrator Certificate is valid till 10/25/25. LPA reviewed clients P&I and did not observe any discrepancies. LPA observed and notified Program Director that licensing fees are due on 07/05/24, LPA provide the PIN and it was paid while LPA was conducting visit.
Safety LPA observed the smoke detectors and carbon monoxide detector to be operable. LPA observed a fully charged fire extinguisher last serviced on 03/15/24, located in the kitchen. The last emergency drill was conducted on 07/01/24. The facility has a working landline telephone. LPA observed the facility’s Emergency and Disaster Plan posted. LPA observed all required posting, posted throughout the facility. There are no firearms or ammunition kept on the premises.
Medications LPA observed medications secured in a locked cabinet in the pantry

Continued on LIC809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
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: 07/03/2024
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and are inaccessible to Clients. LPA observed medications to be in their original packaging. LPA reviewed the medications and Medication Administration Record (MAR) for four (4) clients. LPA observed four (4) out of four (4) client’s MARs and medication are consistent with properly documented records.
Infection Control In the entrance, LPA observed a sanitizing station that consist of hand sanitizer, gloves, and face masks. LPA observed a 30-day supply of Personal Protective Equipment (PPE). LPA observed all required infection control signs posted throughout the facility.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator, Suyono ‘John’ Wong, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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