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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201977
Report Date: 04/18/2022
Date Signed: 04/18/2022 02:19:37 PM


Document Has Been Signed on 04/18/2022 02:19 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:SANCTUARY, THEFACILITY NUMBER:
198201977
ADMINISTRATOR:CATHERINE RAYMUNDOFACILITY TYPE:
740
ADDRESS:21410 MADRONA AVENUETELEPHONE:
(424) 558-3134
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 4DATE:
04/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:CATHERINE RAYMUNDOTIME COMPLETED:
02:15 PM
NARRATIVE
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On 4/18/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiencies observed during an unrelated 10-day complaint visit at this facility. LPA met with Licensee/Administrator Catherine Raymundo who assisted with the visit.

LPA observed Resident #2 who has a dementia has no current medical assessment. LPA observed R#2's physician's report was dated 6/24/2019.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, Type B deficiency was observed and being cited today in violation of California Code of Regulations.

Exit interview conducted and a copy of this report and appeal rights were furnished to Licensee/Administrator Catherine Raymundo.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
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 04/18/2022 02:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: SANCTUARY, THE
FACILITY NUMBER: 198201977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited

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87705 Care of Persons with Dementia
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement was not met as evidenced by:
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Based on observation and interview with the licensee/administrator, Resident #2 who has a dementia has no current medical assessment. LPA observed R#2's physician's report is dated 6/24/2019. This poses a potential risk to health, safety and/or rights of 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: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
LIC809 (FAS) - (06/04)
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