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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204621
Report Date: 05/07/2025
Date Signed: 05/07/2025 04:43:15 PM

Document Has Been Signed on 05/07/2025 04:43 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SEDONA GUEST HOMEFACILITY NUMBER:
198204621
ADMINISTRATOR/
DIRECTOR:		ANTONIO ARBOLEDAFACILITY TYPE:
740
ADDRESS:21635 HOWARD STREETTELEPHONE:
(310) 792-9020
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 4DATE:
05/07/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:18 PM
MET WITH:Nicanor SantosTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 05/07/2025 Licensing Program Analyst (LPA) Jose Anguiano and Licensing Program Analyst Ernand Dabuet conducted a continuation unannounced visit to facility Sedona Guest Home. The purpose of today’s visit was to conduct the one- year inspection, LPA met with Caregiver Nicanor Santos. Facility is licensed to serve clients 60 years of age and older with a capacity of 6 non- ambulatory residents. Currently the facility has 4 residents in care and 1 resident in Home Health with a total of 4 census. The facility does not have an approved hospice waiver.

According to the annual inspection on 04/23/25, LPA Anguiano identified the following deficiencies during that inspection visit and returned to the facility to cite deficiencies from the prior inspection visit.

DEFICIENCY’s:

During the inspection, LPA Anguiano observed that facility failed to notify CCL of alterations done to the garage as a 2-bedroom living space was added to the physical plant. Staff 1-3 first aid (CPR) were found to be expired. Resident’s medications were not stored and locked securely and were accessible to residents. Residents (MAR) PRN medication records were found to be incomplete since 04/09/2025.

Deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Nicanor Santos.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Jose Anguiano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/07/2025 04:43 PM - It Cannot Be Edited


Created By: Jose Anguiano On 05/07/2025 at 01:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2025
Section Cited
CCR
87305(a)(b)

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87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit.The licensing agency may require the facility to acquire a local building inspection...to health and safety exists.
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 Licensee administrator shall read title 22, section 87305 and send a written statement to CCL a plan of action by the due date. LIcensee will request STD 850, Facility Sketch, and LIC200. The plan is due to the CCLD/El Segundo ASC offfice by 06/07/2025 fax at (424)544-1016
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 This requirement is not as evidence by: Based on observtation and records review the facility failed to notify CCL of alterataions done to the garage as a 2 bedroom living space added to the physical plant. This poses a potential health and safety or personal rights risk to persons in care.
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Type B
05/21/2025
Section Cited
CCR87411(c)(1)

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87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
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Licensee or administrator shall have first aid certificates for staff 1-3 by due date indicated. The plan is due to the CCLD/El Segundo ASC offfice by 05/21/2025 fax at (424)544-1016
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 This requirement is not as evidence by: Based on observtationa and records review staff had 3 expired first aid CPR certificates. This poses a potential health and safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:
Jose Anguiano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/07/2025 04:43 PM - It Cannot Be Edited


Created By: Jose Anguiano On 05/07/2025 at 02:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2025
Section Cited
CCR
87465(h)(2)

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87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Licensee administrator shall read title 22, section 87465 and send a written statement to CCL a plan of action by the due date. The facility shall store all medications in a locked stoarge. The plan is due to the CCLD/El Segundo ASC offfice by 05/08/2025 fax at (424) 544-1016
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 This requirement is not met as evidence by: Based on observation LPA observed medications are not stored and locked securely and accessible to residents.This poses an immediate health and safety or personal rights risk to persons in care.
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Type B
05/21/2025
Section Cited
CCR47465(d)(3)

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47465 If the resident is unable to determine... following requirements are met: (3)The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.
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Licensee administrator shall read title 22, section 47465 and send a written statement to CCL a plan of action by the due date. The facility shall send proof of documentted and maintained (MAR) for residnets in care. The plan is due to the CCLD/El Segundo ASC offfice by 05/21/2025 fax at (424) 544-1016
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This requirement is not as evidence by: Based on observtation and records review staff had incomplete (MAR) since 04/09/2025 This poses a potential health and safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:
Jose Anguiano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025


LIC809 (FAS) - (06/04)
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