198204012-12-3-2024-11-AS-WGIS-DBM2TQ-20241203164107

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204012
Report Date: 12/03/2024
Date Signed: 12/03/2024 04:41:17 PM

Document Has Been Signed on 12/03/2024 04:41 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ATKINSON CARE HOME		FACILITY NUMBER:	198204012
ADMINISTRATOR/ DIRECTOR:	MUQEET D. DADABHOY		FACILITY TYPE:	740
ADDRESS:	17035 ATKINSON AVENUE		TELEPHONE:	(310) 819-8218
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY: 6		CENSUS: 5	DATE:	12/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:14 PM
MET WITH:	Edilberto Bernardino		TIME VISIT/ INSPECTION COMPLETED:	04:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/03/24, the department conducted an unannounced annual visit to the facility listed above. LPA met with Administrator, Edilberto Bernardino, and the purpose of today’s visit was explained. The facility is licensed to serve 6 non-ambulatory residents aged 60 and above. The facility has an approved hospice waiver for 6 residents. Currently there are five (5) residents residing in the facility. Physical Plant/Structure The facility is a two-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, two (2) resident bathrooms, living room, dining area, kitchen, detached garage. The second floor consist of an office area, staff rest/break room, and bathroom. In the backyard the department observed two (2) sheds used for storage, a shaded patio with table and chairs. The department observed walkways outside the facility to be clean, clear, and free of debris, hazards, and obstructions. The gate on the side of the facility opens easily from the inside to exit. All ramps had secured safety handrails. The department did not observe any bodies of water on the premises. Bedrooms The department inspected all resident rooms and observed them to be clean and in good repair. All bedrooms had the required furniture including a bed(s), dresser(s), nightstand, chair(s), and ample storage space for resident’s (1) Continued on LIC809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ATKINSON CARE HOME	FACILITY NUMBER: 198204012
	VISIT DATE: 12/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

personal belongings. The department observed the resident beds had the required
linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. The department observed an ample supply of lines and comforter stocked at the time of visit and were observed in good repair. The department observed all resident bedrooms had ample lighting.
Bathrooms All bathrooms were found to be within Title 22 regulation and were observed clean and operational. The department observed the shower has a nonskid mat and secured safety handrails. The department observed an ample supply of towels in good repair. The department observed baskets and storage space for residents’ personal hygiene products. The department observed an ample supply of hygiene products secured in a cabinet in the garage. The water temperature in the bathrooms measured 115.1-degrees and 116.7-degrees Fahrenheit.
Kitchen The department observed the kitchen to be clean and sanitary during the time of visit. All appliances were observed operable and in good repair. The department observed an ample supply of cookware, dishware, and cutleries. The department observed a 3-day supply of non-perishable foods and a 7-day supply of perishable foods. The department observed sharps and knives to be secured in a locked drawer in the kitchen and are inaccessible to residents. The department observed cleaning supplies secured in the cabinet under the kitchen sink and are inaccessible to residents. The water temperature measured 114.8-degrees Fahrenheit.

(2) Continued on LIC809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ATKINSON CARE HOME	FACILITY NUMBER: 198204012
	VISIT DATE: 12/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Common Areas During the time of visit the facility was observed appropriately
furnished. The department observed in the living room a large couch and recliners to accommodate all residents. The department observed games, activities, and
puzzles available for resident use. The dining room has a large table to accommodate all residents. All rooms were observed with ample lighting. All walkways and hallways in the facility were observed clean, clear, and free of obstructions and hazards. The facility was maintained at a comfortable temperature.
Files The department observed resident and staff files secured in a cabinet in the kitchen. The department reviewed the files for five (5) residents and observed they had the required documents. The department reviewed the files for the Administrator and three (3) staff files and observed they had the required documents, training, and certification. The facility has Liability Insurance through Acord valid till 07/01/25.
Medications The department observed all centrally stored medications secured in a locked cabinet in the kitchen. The department observed all medications were in their original packaging. The department reviewed the medications and Medication Administration Record (MAR) for five (5) residents. Five (5) out of five (5) resident’s MARs and medication are consistent with properly documented records.
Safety The department observed a fully charged fire extinguisher in the kitchen last serviced on 10/30/23. The last emergency drill was conducted on 11/07/24. Smoke detectors and carbon monoxide detectors are operable. The facility has a

(3) Continued on LIC809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ATKINSON CARE HOME	FACILITY NUMBER: 198204012
	VISIT DATE: 12/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

working landline telephone. The department observed all required signs and documents posted in a hallway in the facility. The department inspected the First
Aid kit and found it contains the required items and a current manual.
Infection Control During the visit, the department observed the facility's infection control practices. Upon entry, the department observed a sanitizing station with a visitor log. The department observed required Infection Control postings throughout the facility. The department observed a 90-day supply of PPEs stored in the garage.

During today’s visit, the department did not observe or cite any deficiencies.

An exit interview was conducted with Administrator, Edilberto Bernardino, and a copy of this report was provided.

(4)

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4