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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602996
Report Date: 01/13/2024
Date Signed: 01/13/2024 04:00:40 PM

Document Has Been Signed on 01/13/2024 04:00 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:SAR ADULT HOME CAREFACILITY NUMBER:
198602996
ADMINISTRATOR:SAR, VASHNAFACILITY TYPE:
735
ADDRESS:926 E 163RD STTELEPHONE:
(562) 301-6726
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 3DATE:
01/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Vash SarTIME COMPLETED:
03:39 PM
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On 01/13/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the administrator Vash Sar. LPA explained the purpose of today’s visit. The facility is licensed to operate for (4) ambulatory adults ages 18 through 59. The consumers are South Central Regional Center clients.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (3) clients' rooms, two (2) common bathrooms, (1) staff bathroom, a laundry area, a living area, a dining area, a kitchen, a garage occupied as an activity room, and an office room.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. Bathrooms were operational. The water temperature measured 105.4 degrees F. A comfortable temperature was maintained in the facility at 70 degrees F.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) was observed to be maintained in order and accurately. A working landline telephone was available and operable.

Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SAR ADULT HOME CARE
FACILITY NUMBER: 198602996
VISIT DATE: 01/13/2024
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An audit review of client #1-#2 (C1-C4) files and staff #1-#4 (S1-S4) personnel files. An audit of clients P&I was found to be accurate and complete. Interviews conducted with (2) clients and (2) staff. The facility currently has a current surety bond. The facility is current on CCL license annual fees. A current Administrators Certificate for Vash Sar #6044370735 Expiration 05/30/25.

No deficiencies were observed during this inspection visit.

An exit interview was conducted and a copy of this report was provided to administrator Vash Sar.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024
LIC809 (FAS) - (06/04)
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