191600749-10-21-2023-11-AS-EDAT-CWTUF8-20231021153220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191600749
Report Date: 10/21/2023
Date Signed: 10/21/2023 03:32:28 PM

Document Has Been Signed on 10/21/2023 03:32 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 SORRENTO		FACILITY NUMBER:	191600749
ADMINISTRATOR:	CARLA CHAN		FACILITY TYPE:	740
ADDRESS:	23450 MADISON		TELEPHONE:	(310) 539-6826
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	145	CENSUS: 111	DATE:	10/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Carmen Fernandez		TIME COMPLETED:	03:07 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	On 10/21/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Supervisor Carmen Fernandez. 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 resident's personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #127; #135; #141; #223 and #236; and #253 water temperature range from 102.0 -116.4 degrees F. and room temperature range from 74 - 77 degrees F., call buttons, and smoke and carbon monoxide are all in operating 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. A review of Fire & Earthquake Drills were completed for AM, PM and NOC shift on 07/28/23. Several working landline phones are available on-site. A review of Medication Administration Records found to be in order and accurate. Evaluation Report continues on LIC 809C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023

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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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: 10/21/2023

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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 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.

An audit of resident's service records for resident #1-#6 (R1-R6) and staff personnel records for staff #1-#6 (S1-S6) were accurate and complete. Interviews were conducted with (5) residents and (4) staff. The facility is current on Community Care Licensing annual fees.

No Deficiencies were identified during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Carmen Fernandez.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023

LIC809 (FAS) - (06/04)

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