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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203238
Report Date: 10/02/2022
Date Signed: 10/02/2022 12:38:46 PM


Document Has Been Signed on 10/02/2022 12:38 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
EL SEGUNDO, 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: 38DATE:
10/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Maggie Ornelas TIME COMPLETED:
12:45 PM
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On 10/02/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Maggie Ornelas. LPA explained the purpose of today’s visit. The facility is licensed to serve (70) non-ambulatory elderly adults ages 60 and above. The facility is approved for (4) hospice residents.

The facility is a single-story structure located in a commercial neighborhood. It consists of the following: (35) resident bedrooms. Each room has a bathroom in the unit. The facility houses an activity room, dining area, kitchen, administrative offices, and outside patio area.

LPA toured the physical plant with Ornelas. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #136; #137; #149: #151: #154 and #158 and call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 109.5 – 111.2 degrees F. The room temperature ranged from 76 – 78 degrees F.

LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 08/14/22. Several working landline phones are available on-site. A review of (10) residents' service files (R1-R10) and (10) staff personnel files (S1-S10) and Medication Administration Records (MAR) were maintained in order.
Evaluation Report continues on LIC 809-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SOUTH BAY SENIOR LIVING
FACILITY NUMBER: 198203238
VISIT DATE: 10/02/2022
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INFECTION CONTROL:
LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of residents' COVID vaccinations was conducted for (R1-R10) and staff (S1-S10). The facility has provided CCLD with an approved Mitigation Plan and has submitted an Infection Control Plan 2022 to CCLD. A 2022 Monkey Pox Inspection Control was submitted to CCLD.

No Deficiencies were identified during this inspection visit.

Maggie Ornelas was provided with a copy of the report and an exit interview was conducted.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2022
LIC809 (FAS) - (06/04)
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