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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607671
Report Date: 04/03/2025
Date Signed: 04/03/2025 05:05:46 PM

Document Has Been Signed on 04/03/2025 05:05 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: 5DATE:
04/03/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Ana TojoTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 04/03/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced continuation Annual Visit at the facility listed above. LPA met with Administrator, Ana Tojo, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is approved for six (6) non-ambulatory clients over the age of 59; two (2) of which may be bedridden. There are currently five (5) residents in care residing at the facility and all were home during time of visit.
Physical Plant/Structure The facility is a single-story home located in a residential neighborhood. The facility has four (4) resident rooms, living room, dining room, kitchen, two (2) bathrooms, laundry area, attached garage, and outside patio with table, chairs, and umbrella. All walkways were observed clean, clear, and free of obstructions, hazards, and debris. There were no bodies of water observed on the premises.
Bedrooms LPA inspected all resident bedrooms. LPA observed all rooms have the required furniture, including a bed(s), dresser(s), nightstand(s), chair(s), and storage space for personal belongings. LPA observed all beds have the required
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: KIZUNA ASSISTED LIVING
FACILITY NUMBER: 197607671
VISIT DATE: 04/03/2025
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linens, including a mattress cover, fitted sheets, blankets, comforter, and pillows. LPA observed an ample supply of linens stored in the closet. All beds and bedding supplies were observed in good repair. LPA observed all bedrooms have ample lighting.
Bathrooms LPA inspected all bathrooms and observed them to be operational and within Tittle 22 regulations. All showers were observed clean and free of mold and/or mildew. All showers have a shower chair and nonskid mats. LPA observed an ample supply of toiletries for residents. LPA observed the bathrooms have secured safety handrails. The water temperature measured 117.2-degrees and 115.2-degrees Fahrenheit. LPA observed cleaning supplies are secured in cabinets in the bathrooms and are inaccessible to residents.
Kitchen LPA inspected the kitchen and found it to be clean and sanitary. All appliances were observed operational and in good repair. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods properly stored, packaged, and labeled. An additional supply of food and an emergency supply of food and water are stored in the garage. LPA observed knives and sharps secured in a locked drawer and are inaccessible to residents. LPA observed cleaning supplies secured in a locked cabinet under the kitchen sink and are inaccessible to residents. The water temperature measured 117.0-degrees Fahrenheit.
Common Rooms In the living room, LPA observed a couch and two (2) recliners available for resident use. LPA observed the dining room has a large table with chairs to accommodate all residents. When LPA arrived at the facility, residents were playing bingo in the dining room. The facility was appropriately furnished
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: KIZUNA ASSISTED LIVING
FACILITY NUMBER: 197607671
VISIT DATE: 04/03/2025
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during the time of visit. The facility was maintained at a comfortable temperature during time of visit.
Safety LPA observed all smoke/carbon monoxide detectors are operable. LPA observed a fully charged fire extinguisher mounted on the wall in the laundry area. The last emergency drill was conducted on 02/20/25. The last visit from the Torrance Fire Inspector was conducted on 11/25/2024. LPA observed all required licensing postings throughout the facility. The facility has a working landline telephone. LPA inspected the First Aid kits and found it were fully stocked and had the required items including the manual. There are no security bars over the window. No firearms or ammunition are stored on the premises.
Infection Control During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance with a visitor’s log, thermometer, and masks available. PPE supplies are readily available to staff, and an additional 90+ day supply of PPE was observed stored in the garage. Sufficient paper, cleaning, and disinfecting supplies were observed in the garage. LPA observed staff wearing face covering. LPA observed required infection control postings throughout the facility.

During today's visit LPA did not observe or cite any deficiencies.

An exit interview was conducted with Administrator, Ana Tojo, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC809 (FAS) - (06/04)
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