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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203238
Report Date: 04/26/2021
Date Signed: 06/22/2021 11:30:38 AM

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
MONTEREY PARK, CA 91754
FACILITY NAME:SOUTH BAY SENIOR LIVINGFACILITY NUMBER:
198203238
ADMINISTRATOR:MAGGIE ORNELASFACILITY TYPE:
740
ADDRESS:22711 S. VERMONT AVE.TELEPHONE:
(310) 320-3318
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY:70CENSUS: 30DATE:
04/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Maggie OrnelasTIME COMPLETED:
10:30 AM
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On 04/26/2021 Licensing Program Analyst (LPA) Don Senaha conducted a Case Management visit at South Bay Senior Living. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually via facetime with Maggie Ornelas/Administrator. LPA explained the purpose of the visit was to gather information.

LPA Senaha received a self-reported incident report (LIC 624) via email on 04/23/2021 from Administrator Maggie Ornelas regarding an incident involving staff and a client. Staff (S1) stated another staff (S2) was physical with a client (C1) and staff (S1) had to intervene.

Administrator stated they are conducting an internal investigation and staff (S2) will remain off schedule until investigation is fully completed. Administrator notified both the resident’s Power of Attorney and the local Ombudsman of the incident.

A plant inspection was conducted of the facility and no deficiencies were found. LPA requested a copy of the staff and resident rosters, copy of statements from staff (S1-S2), emergency/ID information, appraisal/needs and service plan, physicians report and admission agreement for client (C1).

A telephonic exit interview was conducted with Maggie Ornelas and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don SenahaTELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
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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