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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320115
Report Date: 01/25/2024
Date Signed: 01/25/2024 11:56:15 AM


Document Has Been Signed on 01/25/2024 11:56 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:SAWTELLE ONE, LLCFACILITY NUMBER:
198320115
ADMINISTRATOR:BRENDA LEDEZMAFACILITY TYPE:
740
ADDRESS:4626/4630 SAWTELLE BLVDTELEPHONE:
(310) 301-8181
CITY:LOS ANGELESSTATE: CAZIP CODE:
90230
CAPACITY:6CENSUS: 6DATE:
01/25/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Guadalupe Acosta-House ManagerTIME COMPLETED:
12:00 PM
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On 1/25/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Guadalupe Acosta/House Manager. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above. Approved hospice waiver for (4). Currently the facility has (6) residents.


The facility is a three-story, 12 bedrooms, and 13 bathrooms single-family home located in a residential neighborhood. The facility has an upstairs and downstairs, elevator, cameras in common areas, lobby, check-in station, living/family room, library area, office/medication room, dining area, kitchen, garage, a locked supply closet, laundry room, shaded area, indoor/outdoor activity areas. The front and side yard landscape are in good condition at the time of the visit.

LPA Iniguez toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (3) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected the carbon monoxide detectors combo were in operable conditions. The water temperature properly measured between 105°-120°F: Kitchen 109.7°F, Bathroom #1:107.7°F, Bathroom #2:106.8°F and Bathroom #3:107.5°F

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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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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: SAWTELLE ONE, LLC
FACILITY NUMBER: 198320115
VISIT DATE: 01/25/2024
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LPA Iniguez observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed. 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. A review of (3) residents' service files, (3) staff personnel files and (3) Medication Administration Records (MAR) was performed. The first AID kit was checked. Last disaster drill performed on:1/1/24. Technical Advice given regarding documenting medications on a separate place.

LPA observed the facility's infection control practices. A copy of the liability insurance will be emailed to LPA.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.



An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Guadalupe Acosta/House Manager.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
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