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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607718
Report Date: 09/17/2021
Date Signed: 09/19/2021 01:47:22 PM

Document Has Been Signed on 09/19/2021 01:47 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
MONTERY PARK, CA 91754
FACILITY NAME:CENTINELA ASSISTED LIVING CENTREFACILITY NUMBER:
197607718
ADMINISTRATOR:GWENDOLYN CRAIGFACILITY TYPE:
740
ADDRESS:1000 S FLOWER STTELEPHONE:
(310) 674-3216
CITY:INGLEWOODSTATE: CAZIP CODE:
90301
CAPACITY: 96CENSUS: 55DATE:
09/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Gwendolyn Craig & Elizabeth HernandezTIME COMPLETED:
11:28 AM
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On 09/17/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit at this facility and met with the Administrator Gwendolyn Craig and the Department of Social Services Elizabeth Hernandez and explained the purpose of today’s visit is to conduct a plant inspection and health and safety check.

The Department had received supplemental information on 07/19/21 for complaint #11-AS-20210709155908 after a 10-day visit was already conducted. Resident #1 (R1) was involved in a verbal exchange with staff #1 (S1). An investigation was conducted, and it included interviews with (R1) and (S1) and other staff members. (S1) admitted in the heat of verbal exchanges, he called (R1) an indecent word and that the facility failed to safeguard (R1) an environment free from verbal abuse.

Based on interviews and records reviews, there is sufficient evidence to support the facility violated Title 22 Division 6 Chapter 8 regulations noted on LIC 809-D.

A violation is issued, and an exit interview is conducted with Elizabeth Hernandez.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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Document Has Been Signed on 09/19/2021 01:47 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 09/17/2021 at 11:20 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: CENTINELA ASSISTED LIVING CENTRE
FACILITY NUMBER: 197607718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2021
Section Cited
CCR
87413(a)(2)

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87413(a)(2) Personnel – Operations (a) in each facility: (2) care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice.

This requirement was not met as evidenced by:
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The licensee will create a plan to ensure that all staff performs knowledge of and conforms to applicable laws, rules and regulations will 87413 Incidental Medical and Dental Care Regulations. Plan of correction will be submitted by POC due date: 09/24/21.
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Based on interview and record review an admission from (S1) who had verbal exchanges with (R1), failed to give (R1) an environment free from verbal abuse. The violation poses a potential a potential health and safety risk to residents in care.
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The licensee corrected this violation during the visit on 09/17/21. The administrator investigated the incident with a statement in writing from (S1). The administration will continue to provide in-service training on ethics and a review of Title 22 87413 regulations.

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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021


LIC809 (FAS) - (06/04)
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