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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607671
Report Date: 05/17/2022
Date Signed: 05/17/2022 05:25:26 PM


Document Has Been Signed on 05/17/2022 05:25 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:KIZUNA ASSISTED LIVINGFACILITY NUMBER:
197607671
ADMINISTRATOR:ANA ZUNIGA-MARTINEZFACILITY TYPE:
740
ADDRESS:18349 AMIE AVE.TELEPHONE:
(310) 921-2029
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY:6CENSUS: 4DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ana Tojo AdministratorTIME COMPLETED:
12:42 PM
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Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Ana Tojo Administrator, the purpose of today’s visit was explained. There are currently (4) residents in the facility. (3) residents are ambulatory and (1) is non-ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists (4) bedrooms, (2) full bathrooms, shaded back yard, front area, laundry area and attached 2 car garage. The facility is located in the back house

LPA Randle and Ana Tojo toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. The bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Residents Medications and files are current. LPA Randle reviewed resident file and medication record. Staff file is current. LPA Randle reviewed staff file. Food supply of perishable and nonperishable food is within title 22 regulations, hot water temperature is 118 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 1 fire extinguishers were fully charged. First Aid kit complete and with Manual LPA observed scissors tweezers and thermometer. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged, and temperature checked, sanitizer/soap in the staff bathroom and additional sanitation supplies are locked in the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The resident’s temperatures are checked and logged once a day. PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Ana Tojo Administrator and copy of report provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 395-3554
LICENSING EVALUATOR NAME: Jeremiah RandleTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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