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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607671
Report Date: 03/25/2024
Date Signed: 03/25/2024 04:50:35 PM


Document Has Been Signed on 03/25/2024 04:50 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:ANA ZUNIGA-MARTINEZFACILITY TYPE:
740
ADDRESS:18349 AMIE AVE.TELEPHONE:
(310) 921-2029
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY:6CENSUS: 4DATE:
03/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Ana TojoTIME COMPLETED:
04:00 PM
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On 03/25/24, 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. The facility is approved for six (6) non-ambulatory clients over the age of 59; two of which may be bedridden. There are currently four (4) residents in care residing at the facility and all were home during time of visit.
Structure Facility is a single-story family home located in a residential area; facility has four (4) resident rooms, living room, dining room, kitchen, two (2) full bathrooms, laundry area, and an attached garage.
Physical Plant LPA and administrator toured the inside and outside grounds of the facility. LPA observed a table, chairs, and umbrella. All walkways were clean, clear, and free of obstructions, hazards, and debris. There are no bodies of water on the premises.
Bedrooms LPA inspected all rooms. Bedrooms 1, 2, and 3 are private and bedroom 4 is shared. All rooms had the required furniture including a bed, dresser, nightstand, chair, and storage space for personal belongings. Two beds had half side rails, per physician’s orders. Beds and bedding supplies were in good condition. LPA observed all beds had the required linens including a mattress
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2024
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: KIZUNA ASSISTED LIVING
FACILITY NUMBER: 197607671
VISIT DATE: 03/25/2024
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cover, fitted sheets, blankets, comforter, and pillow. Additional linens were observed in in the laundry room. LPA observed ample lighting provided in bedrooms.
Bathroom LPA inspected all bathrooms. All bathrooms are equipped with a shower, washbasin, and toilet. All bathrooms were observed to have ample hand soap and paper towels. All bathrooms had secured safety handrails in the showers and next to the toilets. All showers had nonskid mats and shower chairs. LPA observed an ample supply of toiletries. The hot water temperature in the bathrooms measured 115.2-degrees to 107.3-degrees Fahrenheit. All bathrooms were found to be clean and sanitary at time of visit.
Kitchen LPA toured the kitchen area and observed it to be clean and sanitary. All appliances were in good working repair. LPA observed an ample supply of cutleries, cookware, and dishware in good repair. LPA observed a 3-day supply of perishable and a 10-day supply of non-perishable food. All food was observed to be stored, packaged, labeled and dated. Additional, supply of food and emergency food is stored on shelves in the garage and in an extra refrigerator. LPA observed knives and other sharps to be secured in a locked drawer and are inaccessible to residents. LPA observed all toxins and cleaning supplies secured in a locked cabinet under the sink and are inaccessible to residents. The water temperature measured 109.2-degrees Fahrenheit.
Common Rooms LPA observed ample seating in the living room to accommodate all residents. The dining room has a large table to accommodate all residents to seat comfortably and to spread out.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
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: 03/25/2024
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LPA observed games and activities available for residents. All rooms and hallways had ample lighting. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards.

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 12/01/24. The sprinkler system was last serviced in August of 2023. 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. 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 was informed that all staff and clients have been vaccinated and boosted. LPA observed required infection control postings throughout the facility.
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 four (4) out of four (4) client’s MARs and medication are consistent with properly documented records.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
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: 03/25/2024
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Files/Interviews LPA reviewed all resident’s files and found they contained the required documents. LPA interviewed two (2) residents and they were happy the care and service they receive at the facility. LPA reviewed four (4) staff files and found they contained the required documents, certification, and training. LPA conducted one (1) staff interview. Administrator was informed Licensing Fees were due on 03/12/24. Licensee informed LPA and Administrator it was paid six weeks ago via check.

No deficiencies were observed or cited during today’s visit. An exit interview was conducted, and a copy of this report was emailed to administrator, Ana Tojo.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC809 (FAS) - (06/04)
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