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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003944
Report Date: 07/24/2024
Date Signed: 07/24/2024 02:58:20 PM

Document Has Been Signed on 07/24/2024 02:58 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:POPPY STREET HOMEFACILITY NUMBER:
306003944
ADMINISTRATOR/
DIRECTOR:
RODRIGO MATEOFACILITY TYPE:
735
ADDRESS:3450 E. POPPY STREETTELEPHONE:
(562) 210-5004
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 4CENSUS: 4DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:29 PM
MET WITH:Barbara MateoTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 07/24/25, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Barbara Mateo as the purpose of today’s visit was explained. The facility is licensed to serve 3 ambulatory and 1 non-ambulatory developmentally disabled adults ages 18-59. Clients are linked to the Harbor Regional center, current facility census is 4. Facility fees are current.

The facility is a single-story structure located in a residential neighborhood and consists of the following: The home consists of 4 Bedrooms, 2 Bathrooms, a linen closet, living room, dining area, kitchen, a stocked pantry, an outdoor shaded activity area, an attached garage that is used for storage and houses a washer and dryer, a refrigerator for staff, and a detached shed in the backyard that is used for extra storage. All client rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed. First aid kit was checked and fully stocked. The last fire drill was conducted on 07/13/24, 1 fire extinguishers fully charged and mounted by the facilities front door, carbon monoxide detectors observed, smoke detectors are operational, a landline and internet service were observed. Toxins and knifes were stored and inaccessible to clients. There are no fire arms nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 3 staff record, 3 client records, 2 medication administration records, no discrepancies were observed. Medications were centrally stored and properly locked.

Exit interview conducted and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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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