<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600749
Report Date: 10/09/2020
Date Signed: 10/15/2020 03:19:56 PM

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:VILLA SORRENTOFACILITY NUMBER:
191600749
ADMINISTRATOR:CARLA CHANFACILITY TYPE:
740
ADDRESS:23450 MADISONTELEPHONE:
(310) 539-6826
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:145CENSUS: 94DATE:
10/09/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Carla ChanTIME COMPLETED:
04:00 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
Licensing Program Analyst (LPA) Don Senaha initiated a case management visit regarding an incident reported to CCLD on 09/29/20 Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted via tele-visit with Carla Chan the facility Administrator.

During todays’ visit LPA interviewed Administrator and staff and toured physical plant.

No deficiencies will be cited at this time, additional investigation is required which includes analysis of the records obtained and follow up interviews with residents.

Exit interview held and a copy of report provided to administrator.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don SenahaTELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020
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 1