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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320119
Report Date: 01/18/2024
Date Signed: 01/18/2024 10:53:07 AM


Document Has Been Signed on 01/18/2024 10:53 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: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: 12DATE:
01/18/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Najma Shaheen/LicenseeTIME COMPLETED:
11:15 AM
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On 1/18/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Najma Shasheen/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (12) non-ambulatory residents ages 60 and above. Facility has an approved hospice waiver for (6) patients. (4) may be bedridden. Rooms #1 and #2 approved for bedridden.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (8) resident's rooms, (4) common bathrooms, a living area, a dining area, a kitchen, and an outside patio area.


LPA Iniguez toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (5) 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 111.7°F, Bathroom #1:108.7°F, Bathroom #2:109.4°F, and Bathroom #3:108.4°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: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
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: MONTOAK SENIOR LIVING INC.
FACILITY NUMBER: 198320119
VISIT DATE: 01/18/2024
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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, 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 (4) residents' service files, (4) staff personnel files and (4) Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit. First AID kit was checked. Last fire disaster drill was on: 12/4/2023

LPA observed the facility's infection control practices. A copy of the liability insurance was provided to LPA during visit.

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 Najma Shasheen /Administrator.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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