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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203238
Report Date: 06/09/2021
Date Signed: 06/22/2021 11:35:14 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: 34DATE:
06/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Maggie OrnealsTIME COMPLETED:
03:15 PM
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On 06/09/2021 Licensing Program Analyst (LPA) Don Senaha conducted a follow up Case Management visit at South Bay Senior Living. Today’s visit was conducted 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.

LPA interviewed Staff (S1) and staff (S3). LPA also conducted interview with Resident (R2).

Administrator stated staff (S2) has not been scheduled to work at the facility since the incident.

An exit interview was conducted with Maggie Ornelas and the signature obtained on the LIC809 and a hard copy will be provided via email.

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

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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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