<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607718
Report Date: 05/17/2022
Date Signed: 05/17/2022 03:51:24 PM

Document Has Been Signed on 05/17/2022 03:51 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: 58DATE:
05/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:49 PM
MET WITH:Elizabeth Hernandez-Social ServicesTIME 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) Stephanie Cifuentes visited facility for an unannounced Case Management Visit to issue deficiency noted during investigation of complaint control number: 11-AS-20220512164519.
LPA Cifuentes met with staff and explained the reason for todays visit. LPA conducted covid-19 risk assessment, based on staff response the facility is clear of Covid-19 infection.

During visit on 5/17/2022 LPA Cifuentes noted that facility had double doors in front of facility. When LPA tried the door on the right side it was noted that door is in disrepair and does not lock.

Exit interview conducted Deficiency cited on LIC809D and a copy of this report and appeal rights are being provided to Elizabeth Hernandez-Social Services.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/17/2022 03:51 PM - It Cannot Be Edited


Created By: Stephanie Cifuentes On 05/17/2022 at 02:59 PM
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: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2022
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will repair door and ensure there is sufficient security for the residents at night while the door is bein repaired. Video of repaired door will be submitted to CCLD via fax by POC due date.
8
9
10
11
12
13
14
Based on observation on 5/17/2022 LPA Cifuentes noted that facility door is in disrepair. This violation possesses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2