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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600749
Report Date: 08/08/2022
Date Signed: 08/08/2022 08:38:36 PM


Document Has Been Signed on 08/08/2022 08:38 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, 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: 93DATE:
08/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:CARLA CHAN TIME COMPLETED:
12:31 PM
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On 08/08/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Carla Chan. LPA explained the purpose of today’s visit. The facility is licensed to serve ambulatory and non-ambulatory elderly adults ages 60 and above. The facility is approved for (15) hospice residents.

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.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #101; #130; #135; #217 and #245 and water temperature, call buttons, and smoke and carbon monoxide are all operable condition.

LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of Fire Drills was observed to be maintained in order and accurate. The last fire drill was performed on 06/06/22 at 1:30 pm. Several working landline phones are available on-site. A record review of (9) residents' service files was conducted for residents #1-#9 (R1-R9).

Evaluation Report continues on LIC 809C
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VILLA SORRENTO
FACILITY NUMBER: 191600749
VISIT DATE: 08/08/2022
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INFECTION CONTROL:
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 staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of residents' COVID vaccinations was conducted for (R1-R9). The facility has provided CCLD with an approved Mitigation Plan and has submitted an Infection Control Plan 2022 to CCLD.

No Deficiencies were identified during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Carla Chan.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC809 (FAS) - (06/04)
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