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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603089
Report Date: 04/25/2024
Date Signed: 04/26/2024 08:54:42 AM

Document Has Been Signed on 04/26/2024 08:54 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/
DIRECTOR:		WILEY, YAVETTEFACILITY TYPE:
735
ADDRESS:11509 CORBY AVETELEPHONE:
(323) 529-4544
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 3DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Keith R ColeTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Required 1 year inspection at the facility and met with Administrator Keith R.Cole and explained the purpose for todays visit. The facility phone number is 562 333 8501.

The facility consist of 3 bedrooms, 1 bathrooms, 1 living room, dining room/office area, kitchen, back yard with out side shaded area, and attached garage.

LPA Wesley conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed one fire extinguisher in dining room area. The water temperature was tested and measured 118.7 degrees F. The last fire drill was conducted on 04/24/24. LPA Wesley received an email of the facility infection control plan and insurance at the time of visit.

Administrators certificate for Keith R Cole 6043766735 for expires on 03/01/2025.

The followin deficiencies have been cited according to the California Code of Regulations, Title 22, Division 6, appeal rights given.

A copy of the LIC 809/LIC 809D was given during the exit interview.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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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Document Has Been Signed on 04/26/2024 08:54 AM - It Cannot Be Edited


Created By: Nicol Wesley On 04/25/2024 at 01:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CARE RESIDENTIAL LLC
FACILITY NUMBER: 198603089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)


This requirement is not met as evidenced by: During the annual inspection LPA Wesley observed that the facility is in need of a thorough clleaning, dusting the ceiling fans, walls, ceilings, computer, cleaning the water cooler, air fryer refrigerator, sink, toilet, bathtub, outside patio entrance to facility.
Deficient Practice Statement
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Based on the LPAs observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Have the facilty thorough cleaned and send proof of corrections via LIC 9098 to Nicol Wesley by POC Date 05/24/2024.
Type B
Section Cited
CCR
80088(f)(1)


This requirement is not met as evidenced by: LPA observed the trash cans in the bathroom, bedrooms, and outside patio area didn't have tight fitting lids.
Deficient Practice Statement
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Based on the LPAs observation the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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The licensee shall replace the trash cans or get the appropriate lids to cover them. send proof of corrections by LIC 9098 to NIcol Wesley by POC date 05/10/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Nicol Wesley
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


LIC809 (FAS) - (06/04)
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