198320013-8-21-2026-11-AS-EGOZ-DX6TYZ-20260821150935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320013
Report Date: 08/21/2026
Date Signed: 08/21/2026 03:09:59 PM

Document Has Been Signed on 08/21/2026 03:09 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:	SENIOR MANOR CARE III		FACILITY NUMBER:	198320013
ADMINISTRATOR/ DIRECTOR:	STEPHEN GRADNEY		FACILITY TYPE:	740
ADDRESS:	2423 SANTA FE AVE		TELEPHONE:	(310) 212-0883
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 6		CENSUS: 6	DATE:	08/21/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:45 AM
MET WITH:	Nicholas Bana		TIME VISIT/ INSPECTION COMPLETED:	03:20 PM

NARRATIVE

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On 08/21/26, the department conducted an unannounced required annual inspection using the Care Inspection Tool. The department met with staff, Nicholas Bana, and explained the purpose of the visit. The department was granted entry to the facility.

The facility is licensed to serve six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility has a hospice waiver approved for six (6) residents. Bedrooms #1, #2, and #4 are approved for non-ambulatory or bedridden residents. Currently there are six (6) residents in the facility. Facility’s annual fees are current.

The facility is a single story structure located in a residential neighborhood and consists of the following: five (5) resident bedrooms, two and one half (2 ½) bathrooms, kitchen with office space, family room/activity area, dining room, staff bedroom, and an outside shaded patio.

Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to residents. Walkways around the home were clear of hazards. The facility is clean, sanitary, and in good repair. There are no security bars or weapons on the premises.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Beds and bedding were in good condition, adequate lighting provided was observed. Walls and floors were clean and in good condition.

Continued on LIC809-C

Stephanie Cifuentes
Elvira Gonzalez
	DATE: 08/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2026

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: SENIOR MANOR CARE III	FACILITY NUMBER: 198320013
	VISIT DATE: 08/21/2026

NARRATIVE

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Bathrooms were checked. Toilets and water faucets worked properly. Grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Hot water temperature properly measured between 105.0-12.0 degrees Fahrenheit. Bath towels, toiletries, and personal hygiene supplies were adequately stocked.

The kitchen was inspected. The department observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet. First Aid kit, along with manual was available. One fire extinguisher was observed in the kitchen area, fully charged. Carbon monoxide and smoke detectors were operational.

The department conducted a review of five (5) staff records

The department conducted a review of six (6) client records, and three (3) Medication Administration Records (MAR), and observed them to be complete and in order, with no discrepancies.

Medications were centrally stored and properly locked. Documents are posted as mandated. Last fire drill was conducted on 08/03/26. Annual fees are current. Liability insurance with Shomer Insurance Services, Policy #RN7032704103, effective 08/19/26, expires 08/19/27.

Deficiencies cited, please see LIC809-D.

An exit interview was conducted and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Elvira Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/21/2026 03:10 PM - It Cannot Be Edited

Created By: Elvira Gonzalez On 08/21/2026 at 12:55 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: SENIOR MANOR CARE III	FACILITY NUMBER: 198320013
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for the water testing in 2 out of 3 bathrooms tested at between 127.0 – 128.0 degrees F, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2026
	Plan of Correction
1 2 3 4	Licensee will adhere to Title 22 Reg 87303 at all times. Licensee will ensure that water supply remain in compliance with hot water temperature of not less than 105 degrees F and not more than 120 degree F. Proof of correction must be sent to LPA Elvira.Gonzalez@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

	Elvira Gonzalez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/21/2026 03:10 PM - It Cannot Be Edited

Created By: Elvira Gonzalez On 08/21/2026 at 12:57 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: SENIOR MANOR CARE III	FACILITY NUMBER: 198320013
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and interviews conducted, the licensee did not comply with the section cited above because the sinks’ handle in bathroom #1 is in disrepair, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/04/2026
	Plan of Correction
1 2 3 4	Licensee will repair above item(s) and submit proof (video) to Elvira.Gonzalez@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

	Elvira Gonzalez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2026

LIC809 (FAS) - (06/04)

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