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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204012
Report Date: 11/20/2025
Date Signed: 12/01/2025 02:40:17 PM

Document Has Been Signed on 12/01/2025 02:40 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 HOMEFACILITY NUMBER:
198204012
ADMINISTRATOR/
DIRECTOR:		MUQEET D. DADABHOYFACILITY TYPE:
740
ADDRESS:17035 ATKINSON AVENUETELEPHONE:
(310) 819-8218
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6CENSUS: 5DATE:
11/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:49 AM
MET WITH:Edilberto BernardinoTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 11/20/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above, using the full CARE tool. 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 consists of an office area, staff rest/break room, and bathroom. In the backyard LPA observed two (2) sheds used for storage, a shaded patio with table and chairs available for resident use. LPA 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 have secured safety handrails. LPA did not observe any bodies of water on the premises.
Bedrooms LPA 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 personal belongings. LPA observed the residents’ beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of lines and comforter stocked at the time of visit and were observed in good repair. LPA observed all resident bedrooms had ample lighting.
Bathrooms All bathrooms were found to be within Title 22 regulation and were observed clean and operational. LPA observed the shower has a nonskid mat, shower chair, and secure safety handrails. LPA observed an ample supply of towels in good repair. LPA observed baskets and storage space for residents’6
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 11/20/2025
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personal hygiene products. LPA observed an ample supply of hygiene products secured in a cabinet in the garage. The water temperature in the bathrooms measured 114.8-degrees and 112.5-degrees Fahrenheit.
Kitchen LPA observed the kitchen to be clean and sanitary during the time of visit. All appliances were observed operable and in good repair. LPA observed an ample supply of cookware, dishware, and cutlery. The department observed a 3-day supply of non-perishable foods and a 7-day supply of perishable foods properly stored, labeled, and dated. LPA observed sharps and knives to be secured in a locked drawer in the kitchen and are inaccessible to residents. LPA observed cleaning supplies secured in the cabinet under the kitchen sink and are inaccessible to residents. The water temperature measured 112.6-degrees Fahrenheit.
Common Areas During the time of visit the facility was observed appropriately furnished. LPA observed in the living room a large couch and recliners to accommodate all residents. LPA 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 LPA observed resident and staff files secured in a cabinet in the kitchen. LPA reviewed the files for five (5) residents and observed they had the required documents. LPA 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 07/01/26. LPA observed Licensing Fees are current.
Medications LPA observed all centrally stored medications secured in a locked cabinet in the kitchen. LPA observed all medications were in their original packaging. LPA reviewed the medications and Medication Administration Record (MAR) for five (5) residents. Five (5) out of five (5) residents’ MARs and medication are consistent with properly documented records.
Safety LPA observed a fully charged fire extinguisher in the kitchen last serviced on 04/29/2025. The last emergency drill was conducted on 11/17/25. Smoke detectors and carbon monoxide detectors are operable. The Emergency and Disaster Plan (LIC610E) was last reviewed on 08/01/2025. The last Fire Prevention Inspection was conducted by the Torrance Fire Department in 04/30/2025. The facility has a working landline telephone. LPA observed all required signs and documents posted in a hallway in the facility. LPA inspected the First Aid kit and found it contains the required items and a current manual.
Infection Control During the visit, LPA observed the facility's infection control practices. Upon entry, LPA observed a sanitizing station with a visitor log. LPA observed required Infection Control postings throughout
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
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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: 11/20/2025
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the facility. LPA observed a 90-day supply of PPEs stored in the garage. The Residential Infection Control Plan was last updated on 07/25/2025.

During today’s visit no deficiencies were observed or cited.

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

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
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