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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603087
Report Date: 07/22/2024
Date Signed: 07/22/2024 03:29:30 PM

Document Has Been Signed on 07/22/2024 03:29 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:CN HOME #8FACILITY NUMBER:
198603087
ADMINISTRATOR/
DIRECTOR:		CAVITE, JONALYFACILITY TYPE:
735
ADDRESS:4743 W 166TH STTELEPHONE:
(310) 612-0978
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY: 4CENSUS: 4DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:21 PM
MET WITH:Ruth Gonzalez, House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 7/22/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with House Manager, Ruth Gonzalez and explained the purpose of today’s visit. The facility is licensed to serve elderly developmentally disabled residents ages 18 – 59. The facility is licensed for 4 non-ambulatory clients; and there are currently four (4) residents in placement.

LPA reviewed all resident files and found they contained the required documents. LPA reviewed five (6) staff files and found they contained the required documents, training, and certification. LPA reviewed the surety bond.

LPA Felisa and Ruth toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (4) client bedrooms, (1) activity room, (1) Office, (2) bathroom, living room, kitchen, dining area, patio, garage used for storage. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. LPA observed all rooms to have the required furniture including a bed, dresser(s), nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms and hallway.

LPA Shirley and Ruth toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored in a drawer in the kitchen inaccessible to clients in care. The medications were locked and stored in a locked cabinet and inaccessible to the resident. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 105.3 degrees Fahrenheit.

Con'd on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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: CN HOME #8
FACILITY NUMBER: 198603087
VISIT DATE: 07/22/2024
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The (2) bathrooms have grab bars and are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

LPA Shirley and Ruth walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen. The backyard is clean and clear of obstructions and hazards, shaded patio area and there are no bodies of water present.

No deficiencies was issued during this visit.


An exit interview was conducted, and a copy of this report was provided to House Manager, Ruth Gonzalez.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC809 (FAS) - (06/04)
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