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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600749
Report Date: 05/17/2024
Date Signed: 05/17/2024 03:58:00 PM


Document Has Been Signed on 05/17/2024 03:58 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:VILLA SORRENTOFACILITY NUMBER:
191600749
ADMINISTRATOR:CARLA CHANFACILITY TYPE:
740
ADDRESS:23450 MADISONTELEPHONE:
(310) 539-6826
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:145CENSUS: 106DATE:
05/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Carla ChanTIME COMPLETED:
04:00 PM
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On 05/17/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above using the full CARE inspection tool. LPA met with Administrator, Carla Chan, and the purpose of today's visit was explained. The facility is licensed to serve ambulatory and non-ambulatory elderly adults ages 60 and above. The facility is approved for (15) hospice residents.
Physical Plant/Structure The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (108) resident bedrooms. Each room has a bathroom in the unit. The facility houses an activity room, dining area, kitchen, beauty shop, administrative offices, and outside patio area. There were no bodies of water or on the premises. LPA observed all walkways around the facility to be clean, clear, and free of obstructions, debris, and hazards.
Rooms LPA inspected 10 resident rooms including room numbers 133, 130,127,126, 125, 235. 241, 245, 246, and 255. LPA observed rooms to be clean and in good repair. LPA observed resident rooms have the required furniture including a bed, dresser, nightstand, chair, and storage space for resident’s personal belongings. LPA observed resident beds have the required linens including a mattress cover, blanket, comforter, and pillows. LPA observed an ample supply of linens in good condition. LPA observed rooms to have ample lighting.

CONTINUED ON LIC9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024
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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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: VILLA SORRENTO
FACILITY NUMBER: 191600749
VISIT DATE: 05/17/2024
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Bathrooms LPA inspected bathrooms in rooms. Bathrooms were found to be within Title 22 Regulations and were operational. All bathroom inspected have secured safety handrails, shower mats, and a shower chair. LPA observed an ample supply of towels in good condition. LPA observed an ample supply of hygiene products. The water temperature measured between 117.3-degrees and 119.8-degrees Fahrenheit.
Common Rooms LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. During facility visit, LPA observed residents participating in morning exercise in the activity room. There is a game area that consists of a pool table, puzzles, games, and activities. LPA observed multiple seating areas for residents. LPA observed the dining rooms have ample seating to accommodate all residents. LPA observed all walkways and hallways were clean,
clear, and free of obstructions and hazards. All hallways and rooms were observed with ample lighting.
Kitchen LPA inspected the commercial kitchen and found it to be clean and sanitary. LPA observed all appliances to be operable and in good repair. LPA observed an ample supply of dishware, cookware, and cutleries in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods properly labeled, stored, and dated.

CONTINUED ON LIC9099-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
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: VILLA SORRENTO
FACILITY NUMBER: 191600749
VISIT DATE: 05/17/2024
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Safety LPA observed several fire extinguishers fully charged. The last emergency drill was conducted on 04/16/24 for all shifts. Smoke and carbon monoxide detectors are operational. LPA tested call button and found them to be in operating condition. The facility has multiple working landline telephones on-site. LPA observed storage area for personal hygiene, cleaning supplies, toxins, and sharps are secured and inaccessible to residents. LPA observed all required documents posted in the facility.
Medications LPA observed Centrally Stored Medication secured in a medication cart locked in the med room. All medications were observed in their original packaging. LPA reviewed the medication for ten (10) residents and the Medication Administration Record and found they were consistent with properly documented records.
Files/Interviews LPA reviewed the files for 7 residents and found they contained the required documents. LPA interviewed 5 residents, and all were happy with the care they receive from the facility staff. LPA reviewed 5 staff files and observed they had the required documents, certification, and training. LPA interviewed 4 staff, and all were able to answer questions regarding policy, procedure, resident’s rights, and resident care. The Administrator Certificate is valid till 05/25/25. LPA observed during file review that the Licensing fees are up to date. LPA received a copy of the facility’s Liability Insurance.

CONTINUED ON LIC-9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
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: VILLA SORRENTO
FACILITY NUMBER: 191600749
VISIT DATE: 05/17/2024
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Infection Control During the visit LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 120-day supply of Personal Protective Equipment (PPE). All mandated infection control posters were posted.

No Deficiencies were observed or cited during this inspection visit.

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

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
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