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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607718
Report Date: 07/05/2022
Date Signed: 07/05/2022 04:58:49 PM

Document Has Been Signed on 07/05/2022 04:58 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: 60DATE:
07/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Gwendolyn CraigTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Stephanie Cifuentes and Antonia Alvizar visited facility for an unannounced case management visit to cite deficiencies that were noted during annual visit. 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 7/5/2022 LPA's Cifuentes and Alvizar noted the following:
-Water in communal bathroom for rooms 57 and 58 is 148.3F Water in room 18 was 122F. Water in room 8 measured at 96F

Exit interview conducted Deficiency cited on LIC809D. A copy of this report and appeal rights are being provided to Gwendolyn craig administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2022
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 07/05/2022 04:58 PM - It Cannot Be Edited


Created By: Stephanie Cifuentes On 07/05/2022 at 04:39 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: 07/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2022
Section Cited
CCR
87303(e)(2)

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Maintenance and Operation
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water...the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
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Administrator will track water temperature for next 24 hours and submit log to CCLD via fax/email by POC due date.
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Based on obsevation, on 7/5/2022 LPA's Cifuentes and Alvizar noted that water in communal bathroom for rooms 57 and 58 is 148.3F Water in room 18 was 122F. Water in room 8 measured at 96F. This is an immediate health and safety risk to residents in care.
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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:Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022


LIC809 (FAS) - (06/04)
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