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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004298
Report Date: 03/06/2024
Date Signed: 03/06/2024 03:02:14 PM

Document Has Been Signed on 03/06/2024 03:02 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:SANDRA'S HOUSEFACILITY NUMBER:
306004298
ADMINISTRATOR:SANDRA BENSONFACILITY TYPE:
735
ADDRESS:2821 E. 57TH ST.TELEPHONE:
(562) 470-6300
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 4CENSUS: 4DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Anabel BerovinosTIME COMPLETED:
03:15 PM
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On 03/06/24 Licensing Program Analyst (LPA) Villegas conducted an unannounced annual inspection visit using the care inspection tool. LPA Villegas met with Administrator Anabel Justice as the purpose of visit was explained. The facility is licensed for four (4) clients, three (3) ambulatory and one (1) Non-ambulatory developmentally disabled adults. Clients are linked with Harbor regional center. Current facility census is (4)

The single story residential home consists of (4) client bedrooms, (2) client bathrooms, living room, dining room, kitchen, a laundry area, office area, de-attached garage with storage area, front yard, backyard with umbrella with table and chairs. Client bedrooms 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. A landline and internet service was observed. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 2 staff records, 2 client records, and 2 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 03/01/24, 2 fire extinguisher fully charged, carbon monoxide and smoke detectors are interconnected and operational.

Exit interview conducted with Administrator Anabel Justice, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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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