197607671-5-20-2023-11-AS-ARID-CRZUQZ-20230520154758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607671
Report Date: 05/20/2023
Date Signed: 05/20/2023 03:48:06 PM

Document Has Been Signed on 05/20/2023 03:48 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:	KIZUNA ASSISTED LIVING		FACILITY NUMBER:	197607671
ADMINISTRATOR:	ANA ZUNIGA-MARTINEZ		FACILITY TYPE:	740
ADDRESS:	18349 AMIE AVE.		TELEPHONE:	(310) 921-2029
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 4	DATE:	05/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:09 AM
MET WITH:	Leonardo Zuniga		TIME COMPLETED:	04:00 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	Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Annual required visit to the above facility using the new Care Inspection tool. LPA was met by Staff Leonardo Zuniga, 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 garage. The facility is located in the back house LPA Antonine Richard and Leonardo Zuniga 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 Antonine Richard reviewed resident file and medication record. LPA reviewed staff files. Staff files are not current. Food supply of perishable and nonperishable food is within title 22 regulations. The Hot water temperature tested 117.5F 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.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2023

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: KIZUNA ASSISTED LIVING	FACILITY NUMBER: 197607671
	VISIT DATE: 05/20/2023

NARRATIVE

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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.

During today's visit there were deficiencies observed. LPA did not observe staff LIC503 Health Screenings, LIC9052 Employee rights, and Medical Training verifications.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies, therefore citations were issued at of the time of visit.

An exit interview conducted with Staff Leonardo Zuniga, plan of correction were developed. A copy of the report and appeals rights were provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/20/2023 03:48 PM - It Cannot Be Edited

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: KIZUNA ASSISTED LIVING	FACILITY NUMBER: 197607671
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/20/2023 03:48 PM - It Cannot Be Edited

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: KIZUNA ASSISTED LIVING	FACILITY NUMBER: 197607671
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation,interview,record review), the licensee did not comply with the section cited above in [2, out of 4 staff, [First Aid Certificate,and health Screening ,were missing. (Celia martinez, Leonardo Zuniga)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	The Administrator agreed to Submit a copy of First Aid Certificate, and Health screening, for each employee to LPA Antonine Richard via email. Antonine.Richard@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2023

LIC809 (FAS) - (06/04)

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