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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203238
Report Date: 08/07/2024
Date Signed: 08/07/2024 09:57:17 AM


Document Has Been Signed on 08/07/2024 09:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



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: 0DATE:
08/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Maggie Ornelas (Administrator), James Simms (Administrator Assistant)TIME COMPLETED:
09:50 AM
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On 08/07/2024 at 8:47 am Licensing Program Analyst (LPA) Hollie Enriquez conducted an unannounced Case Management – Other visit and met with Maggie Ornelas (Administrator) and James Simms (Administrator Assistant). The purpose of the visit was explained.

The facility was licensed to serve 70 non-Ambulatory residents ages 60 and above. The facility had a Hospice Waiver for up to 4 residents. The facility consists of 35 resident rooms with individual bathrooms, 1 public restroom, living room/activity room, kitchen, dining room, and outdoor area.

At 8:50 am Administrator Assistant accompanied LPA through the facility to conduct a tour of all 35 bedrooms and individual bathrooms, living room, activity area and outdoor patio. Medication, dining, and living rooms were toured and observed. Personal belongings have been removed from bedrooms and the rooms are undergoing cleaning, maintenance and upgrades.

There were zero (0) clients in care observed at this facility during the visit. Per Administrator, the last resident relocated 08/05/2024. Administrator surrendered the facility license to LPA.

No Citations issued at this visit.

An exit interview was conducted and copy of report was provided to Administrator.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Hollie EnriquezTELEPHONE: (916) 908-8866
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
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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