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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203238
Report Date: 06/19/2024
Date Signed: 06/19/2024 10:08:30 AM


Document Has Been Signed on 06/19/2024 10:08 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: 38DATE:
06/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:ADMINISTRATOR MAGGIE ORNELASTIME COMPLETED:
10:30 AM
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On 06/19/2024 around 09:00am Licensing Program Analyst (LPA) Jose Calderon initiated an announced Case Management - Other to South Bay Senior Living provide Technical Assistance to the above said facility.
A tour of the facility's common areas was conducted by LPA Calderon was given a tour of the facility's main building by Administrator Maggie Ornelas. The tour consisted of a single-story commercial building, all common areas which included but were not limited to, building entrances, reception areas, office, hallways, public restrooms, dining room, kitchen, pantry, medication storage and patio area.

The LPA Calderon also requested copies of the facility's records which include but are not limited to staff and resident rosters, line list with date of discharge, contact information to new placement locations, submit closure plan. LPA Calderon conducted an interview with Administrator Maggie Ornelas. Administrator Ornelas was advised to submit closure plan, stop accepting new residents and entering into a new admission agreement for new residents. To send a copy of the closure plan to the local ombudsman program and to maintain compliance with Title 22 Regulations. The Administrator Maggie Ornelas will provide updated line list and relocation information for residents bi-weekly by email LPA Calderon.

An exit interview was conducted with Administrator Maggie Ornelas and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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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