198320131-4-29-2021-11-AS-DSEA-C2JW2Q-20210429165443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320131
Report Date: 04/29/2021
Date Signed: 04/29/2021 04:54:56 PM

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:	SEASONS MEMORY CARE AT ROLLING HILLS		FACILITY NUMBER:	198320131
ADMINISTRATOR:	THORNTON, TIERRE		FACILITY TYPE:	740
ADDRESS:	2455 PACIFIC COAST HWY		TELEPHONE:	(424) 282-3463
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	68	CENSUS: 0	DATE:	04/29/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Tierre Thorton		TIME COMPLETED:	01:00 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	On 04/29/2021, Licensing Program Analyst (LPA) Don Senaha conducted an announced visit to the facility for purpose of a pre-licensing evaluation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted via Microsoft Teams with Tierre Thorton. An application was submitted to CCLD on 01/08/2021 for the initial license application for a Residential Care Facility for the Elderly, ages ranging from 60 years and above. The applicant requested capacity of sixty-eight individuals, of which zero (0) ambulatory, zero (0) non-ambulatory, and sixty-eight (68) bedridden. This facility has a dementia care plan. LPA was greeted and accompanied by applicant Tierre Thorton during the inspection. Structure: Facility is a two-story facility situated in a residential neighborhood. The facility has 47 rooms with each room having its own bathroom. There is ample parking provided on the premises. The facility includes, lobby area with chairs and lounge chairs, kitchen, beauty salon, conference rooms, offices and a one (1) elevator. The facility also includes, dining, activity area and laundry rooms on both floors. The kitchen has a walk-in refrigerator and freezer. The exterior is fenced throughout. The passageways and walkways are free from obstructions. There is a patio area with tables and outdoor umbrella for shade. Signal system: The facility has a required signal system in place ‘care predict system’.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

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: SEASONS MEMORY CARE AT ROLLING HILLS	FACILITY NUMBER: 198320131
	VISIT DATE: 04/29/2021

NARRATIVE

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Bedrooms Clients:
The facility had forty-seven (47) bedrooms for clients. All bedrooms have their own bathrooms. All bedrooms include closet space and can be equipped with a bed, night stand, chair, dressers and lights. All rooms include its own heating/air-conditioning unit.

Bathrooms:
Each bedroom has its own bathroom. The facility also has common restrooms on both floors accessible to all residents. All bathrooms have grab bars for toilet and showers. All bathrooms have working toilet, wash basin and shower.

Linens & Hygiene Supplies:
The facility has the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in linen closets on each floor. Facility has supplied invoices of linens ordered.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. exit plan and menu are posted and readily available for review in the lobby area. There are fire extinguishers located throughout the facility mounted on the wall in a case and fully charged.

Food Service:
Facility has a full-service kitchen. Dishes, cups and flatware are stored in the kitchen, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in the kitchen. Food supply was adequately stored in kitchen and refrigerator and consists of the following: Two-day supply of perishable food and seven-day supply of non-perishable food. The facility supplied invoice of the contract of food supplier.

Smoke Detectors:
Smoke and carbon monoxide detectors are located throughout the interior facility and in each room. All are hard wired and operational.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

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: SEASONS MEMORY CARE AT ROLLING HILLS	FACILITY NUMBER: 198320131
	VISIT DATE: 04/29/2021

NARRATIVE

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Appliances:
Stove, oven, microwave, washer, and dryer are in good working condition. There is a walk-in refrigerator/freezer in the facility. The refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit.

Toxins:
All toxins are locked/stored in custodial rooms on both floors.

Medications, First-Aid Kit & Book:
A first aid kit stored in each med tech room on each floor and at the front desk. The first aid kits have been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and available for staff, but inaccessible to clients. Client's medications will be stored in the med tech rooms locked and inaccessible to clients.

Clients & Staff Files:

Records of staff and clients will be stored in locked drawer in the Administrators office.

Reading Material, Games, Equipment & Materials:
The facility has a daily activities calendar. The Activity Director will be responsible for coordinating all activities in the activity area on both floors, commensurate with the plan of operation.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi or pool on the facility grounds.

Fire clearance:

Fire Clearance was approved on 04/07/2021 for a capacity for zero (0) ambulatory, zero (0) non-ambulatory, and sixty-eight (68) bedridden.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

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: SEASONS MEMORY CARE AT ROLLING HILLS	FACILITY NUMBER: 198320131
	VISIT DATE: 04/29/2021

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Component III:
Conducted at the Pre-Licensing visit, on 04/29/2021 at Seasons Memory Care At Rolling Hills, information provided about how to operate the facility within substantial compliance.

LPA observed no corrections during this pre-licensing inspection.

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

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

LIC809 (FAS) - (06/04)

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