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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320119
Report Date: 06/26/2023
Date Signed: 06/26/2023 04:36:38 PM


Document Has Been Signed on 06/26/2023 04:36 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:MONTOAK SENIOR LIVING INC.FACILITY NUMBER:
198320119
ADMINISTRATOR:SHAHEEN, NAJMAFACILITY TYPE:
740
ADDRESS:1700 248TH STREETTELEPHONE:
(310) 406-6193
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:12CENSUS: 10DATE:
06/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:33 PM
MET WITH:Najma Shaheen, AdministratorTIME COMPLETED:
04:49 PM
NARRATIVE
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On 06/26/23 Licensing Program Analyst (LPA) Mario Leon conducted an investigation for the complaint number 11-AS-20230623125848. During this investigation, there was one deficiency observed. See LIC809D.

Appeal rights were provided, an exit interview was conducted and a copy of this report was given to Najma Shaheen, Administrator.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/26/2023 04:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: MONTOAK SENIOR LIVING INC.
FACILITY NUMBER: 198320119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2023
Section Cited
CCR
87355(e)(1)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
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LPA and Administrator Najma Shaheen have agreed that S6 will obtain fingerprint clearance prior to returning to work at the above mentioned facility.
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(1) Obtain a California clearance or a criminal record exemption as required by the Department
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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.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023
LIC809 (FAS) - (06/04)
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