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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607671
Report Date: 03/21/2025
Date Signed: 03/21/2025 03:15:27 PM

Document Has Been Signed on 03/21/2025 03:15 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:KIZUNA ASSISTED LIVINGFACILITY NUMBER:
197607671
ADMINISTRATOR/
DIRECTOR:		ANA ZUNIGA-MARTINEZFACILITY TYPE:
740
ADDRESS:18349 AMIE AVE.TELEPHONE:
(310) 921-2029
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6CENSUS: 6DATE:
03/21/2025
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Ana TojoTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 03/21/25, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced required annual visit using the CARE Inspection Tools. Upon arrival at the facility, LPA Gibbs met with Administrator, Ana Tojo, and explained the purpose of this visit. LPA was granted entry into the facility. The facility is approved for six (6) non-ambulatory clients over the age of 59; two of which may be bedridden. There are currently six (6) residents in care residing at the facility and all were home during time of visit.
Files LPA reviewed six (6) resident files and found they contained the required documents. LPA reviewed three (3) staff files and found they contained the required documents, certification, and training. The Administrator’s certificate is valid till 10/07/2026. During file review, LPA observed Licensing Fees are current.
Medications All medications were observed stored in their originally received containers. Medications are secured in a locked cabinet in the garage and are inaccessible to residents. LPA reviewed medication for all residents, LPA observed six (6) out of six (6) resident’s MARs and medication are consistent with properly documented records.
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 was conducted with Administrator, Ana Tojo, and a copy of this report was provided. LPA will return to complete Annual Visit.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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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