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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602984
Report Date: 04/29/2023
Date Signed: 04/29/2023 02:49:03 PM


Document Has Been Signed on 04/29/2023 02:49 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:ALBERTSON RESIDENTIAL CAREFACILITY NUMBER:
198602984
ADMINISTRATOR:MARTIN, LATIESHAFACILITY TYPE:
735
ADDRESS:13903 S ALBERTSON AVETELEPHONE:
(310) 438-3526
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY:4CENSUS: 3DATE:
04/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Latiesha Martin-AdministratorTIME COMPLETED:
02:48 PM
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On 4/29/2023 at 12:30PM Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Latiesha Martin/Administrator and Mishaun Jackson DSP and the purpose of today’s visit was explained. The facility is licensed to operate for (3) non-ambulatory developmentally disabled or Mentally Ill adults ages 18 through 59. Currently, the home has (3) clients. The clients are from: South Central Los Angeles Regional Center. None the clients have Restricted Health Care Conditions, and none are utilizing postural supports or protective devices.

The facility is a single-story structure located in a residential neighborhood. The home consists of 3 Bedrooms, 1 Bathroom, Living Room, Kitchen, Patio with shaded area and Dining area.

LPA Iniguez and Administrator toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathroom was found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees (Kitchen 113.4F°, Bathroom #1 117.5F°).

Evaluation Report continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ALBERTSON RESIDENTIAL CARE
FACILITY NUMBER: 198602984
VISIT DATE: 04/29/2023
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide/Smoke detectors combo were observed and operational. Fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked.

LPA conducted a records review of (3) client records, (4) staff records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit.


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

An exit interview was conducted and a copy of the Facility Evaluation Report was provided to the Administrator/ Latiesha Martin .
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2023
LIC809 (FAS) - (06/04)
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