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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603089
Report Date: 04/25/2023
Date Signed: 04/26/2023 09:07:35 AM

Document Has Been Signed on 04/26/2023 09:07 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CARE RESIDENTIAL LLCFACILITY NUMBER:
198603089
ADMINISTRATOR:WILEY, YAVETTEFACILITY TYPE:
735
ADDRESS:11509 CORBY AVETELEPHONE:
(323) 529-4544
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 3DATE:
04/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Yavette WileyTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Angelica Rea made an unannounced visit to Care Residential LLC. The purpose of today’s visit was to conduct the Required Inspection. On today’s visit LPA met with Licensee Yavette Wiley and Administrator Keith Cole. The home has 3 residents, 1 non-ambulatory, and 2 ambulatory, none has a restricted health care condition. The facility conducted a fire drill on 1/30/23.

As a part of the inspection, LPA reviewed (3) client records, (2) staff files, and (3) client medications. Currently the facility has (2) clients of which (2) are ambulatory. The facility is vendorized through Harbor Regional Center. Facility is a one story family home with three (3) bedrooms. Each bed room is for one (1) client. There is (1) bathroom for client use. There is also a living room, a kitchen, central air and heating, a dining area, a shaded area located in the backyard. A detached car garage inaccessible to clients. Front and back yard is in good condition at time of visit. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to clients. Bedrooms #1-#3 are equipped with a (1) beds each, a dresser, lamp, chair, overhead lightning for each client. Bathroom #1 has a working toilet, wash basin, and shower. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies were observed. Fire alarms are interconnected and operational. Required postings observed. Water temperature within required tittle 22 regulations.

No deficiencies cited. An exit interview was conducted and a copy of this report was provided to Licensee Yavette Wiley.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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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