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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204012
Report Date: 06/13/2022
Date Signed: 06/13/2022 06:04:59 PM

Document Has Been Signed on 06/13/2022 06:04 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ATKINSON CARE HOMEFACILITY NUMBER:
198204012
ADMINISTRATOR:MUQEET D. DADABHOYFACILITY TYPE:
740
ADDRESS:17035 ATKINSON AVENUETELEPHONE:
(310) 819-8218
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6CENSUS: 2DATE:
06/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Muqueet DadabhoyTIME COMPLETED:
06:30 PM
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On 6/13/22, Licensee Program Analyst (LPA) Martessa Brown was investigating a complaint allegation at the above facility and met with Muqeet Dadaboy. During today’s investigation LPA notice the following health and safety concerns.

At 11:30 AM during today’s visit LPA observed construction work being done in the facility’s living room, hallways and kitchen area.

At 11:30 AM LPA observed there was no stove, refrigerator and cabinets in the kitchen area. LPA went outside of the home and the refrigerator; toaster oven and other kitchen appliances was outside. LPA noticed the refrigerator, rice cooker and a hot plate with a pot sitting on the counter and was plug into a socket located outside.

Administrator stated construction was done around 5/13/22 and did not notify CCLD, Ombudsman and the fire department. He stated construction will be finish in a month.

During today’s visit LPA discussed the with the Administrator plan of corrections and due dates. Deficiencies cited on California code of regulations title 22, division 6, chapter 8.

An exit interview was conducted and a copy the report and the appeal rights were discussed and provided to Leo-Cargiver.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2022
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 06/13/2022 06:04 PM - It Cannot Be Edited


Created By: Martessa Brown On 06/13/2022 at 05:19 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ATKINSON CARE HOME
FACILITY NUMBER: 198204012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2022
Section Cited
CCR
8277(a)(D)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(D) Any incident which threatens the welfare, safety...

This requirement was not met as evidence by:
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Licensee will outline a plan on how he will ensure the health and safety of the residents in care while construction work is being done. He will also complete/notify CCLD, Ombudsman and the fire depart by POC due date.
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Based on LPAs observation construction work was being done inside of the home and Licensee did not notify the proper departments.


This is a potential health and safety risk to clients in care.
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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:Janae Hammond
LICENSING EVALUATOR NAME:Martessa Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022


LIC809 (FAS) - (06/04)
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