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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600749
Report Date: 07/27/2023
Date Signed: 07/27/2023 04:01:20 PM


Document Has Been Signed on 07/27/2023 04:01 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: 116DATE:
07/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Carla Chan Exec DirectorTIME COMPLETED:
04:00 PM
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On 07/27/23 Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced visit to the above named facility. LPA was met by Carla Chan Exec Director (S1). The Purpose of the visit was explained to investigate the " Personal Rights” and conduct a health and safety check on residents in care. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained throughout the facility. LPA observed the facility to be operational and in good repair. Residents were currently sitting in the, activity room, dining room and common areas. Residents did not show any signs of distress or abuse. LPA interviewed S1 regarding incident. LPA interviewed R1 regarding incident. LPA went to Torrance Police Department to obtain a copy of the police report. LPA requested pertinent documents pertaining to the investigation. The following documents were gathered: Resident Roster, Staff Roster, Copy of entire resident file for (R1) and including Admissions Agreement, Needs and Services, physicians report. LPA requested entire personnel file for weekend staff R3. LPA requested facility staff schedules and other pertinent documentation. LPA advised licensee to email to Jeremiah.Randle@dss.ca.gov, any other requested documents not provided. Due to further investigation needed, and analysis of documentation. An exit interview was conducted with Carla Chan Exec Director. No citations issued at this time.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jeremiah RandleTELEPHONE: 323-213-1116
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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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