198320119-12-21-2020-11-AS-ASOO-BWHMTB-20201221085314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320119
Report Date: 12/18/2020
Date Signed: 12/21/2020 08:53:27 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	MONTOAK SENIOR LIVING INC.		FACILITY NUMBER:	198320119
ADMINISTRATOR:	SHAHEEN, NAJMA		FACILITY TYPE:	740
ADDRESS:	1700 248TH STREET		TELEPHONE:	(310) 406-6193
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY:	12	CENSUS: 0	DATE:	12/18/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Najma Shaheen, Licensee		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An application was submitted to Community Care Licensing Department (CCLD) on 05/15/20 for an initial license for an Elderly Facility to serve Elderly Adults for ages 60 years and above. The requested capacity is for (12) Residents, 8 ambulatory and 4 bedridden. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted virtually with Najma Shaheen, the facility Licensee. Licensing Program Analysts (LPA) Ana Soto, conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation. Structure: Facility is a eight (8) bedroom, three (3) full bathroom, and one (1) 1 ½ bathroom, 1 office, single story house with small front porch, detached garage and a wrap around ramp, that goes front of the house to the back of the house. The facility is a gray stucco structure with rear patio and small backyard. Front yard landscape is in good condition. Rear patio is all cement. Signal System: No signal system in the facility. Bedroom Residents: There shall be no more than two residents per bedrooms. bedrooms are designated resident bedrooms properly equipped with regulation guidelines of two beds, two chairs, two night stands, two lamps and overhead lighting. Bedroom Staff: No bedrooms will be used for awake staff. Bathrooms: 3 full bathrooms and 1 1/2 bathroom, all have showers with bars and non-slip mats. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers and menu are posted and readily available for review in dining room bulletin board. Facility has a land line telephone located in the kitchen area. 2 Fire extinguisher, one near kitchen, and the second is by living room they are labeled, they are tagged with current annual checks.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2020

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MONTOAK SENIOR LIVING INC.	FACILITY NUMBER: 198320119
	VISIT DATE: 12/18/2020

NARRATIVE

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Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils will be stored in locked storage drawers in the kitchen drawers. Adequate food supply is stored in kitchen, and consists of the following: 2 day perishables, and 7 week non-perishables. Smoke Detectors: There are 9 hard wired smoke detectors, and 1 battery operated carbon monoxide and smoke detector combo located near kitchen. Appliances: Stove burners, oven, microwave, are in working condition. Facility does not have washer/dryer, laundry room is located in the garage and it is incomplete. There is one refrigerator in the home. The residence is equipped with central heat and air conditioning. Toxins: Cleaning supplies, and toxins are stored in one location: locked cabinet under the sink Water Temperature: Water was tested in bathrooms and kitchen sink within 105-120 degrees Fahrenheit range. Medication, First-Aid Kit & Book: Designated area for centrally stored medication is located in the kitchen with lock. A first-aid kit and manual were not available for inspected . Clients & Staff Files: Designated area for files will be located in the office with locked . Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. . Fire Clearance: Fire clearance does indicate any delayed egress . 2 bedrooms have auditory alarms on exit doors. Component III: Conducted at the Pre-Licensing visit.

The following items must be corrected and proof of correction shall be submitted to the CCLD office to the attention of LPA Soto, by 12/28/20. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. First Aid Kit and Manual
2. Wall around front door needs be repaired with stucco
3. Laundry room must be completed with stucco, electrical wiring, and plumbing.

An exit interview was conducted and a copy of this report has been emailed to the applicant for signature. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2020

LIC809 (FAS) - (06/04)

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