198320249-2-16-2023-11-AS-AINZ-CP4VD6-20230216152012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320249
Report Date: 02/16/2023
Date Signed: 02/16/2023 03:20:17 PM

Document Has Been Signed on 02/16/2023 03:20 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:	SOUTHWOODS LIVING, INC.		FACILITY NUMBER:	198320249
ADMINISTRATOR:	CINCO, TINA		FACILITY TYPE:	740
ADDRESS:	23506 CLEARPOOL PLACE		TELEPHONE:	(424) 250-9123
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY:	6	CENSUS: 6	DATE:	02/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:59 PM
MET WITH:	Tina Cinco-Administrator		TIME COMPLETED:	03:30 PM

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On 2/16/23 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced visit to this facility. The purpose of today’s visit was to conduct an Annual inspection. LPA met with Tina Cinco/Administrator. Facility is licensed for (5) non-ambulatory residents and (1) bedridden resident. The facility has an approved hospice waiver for (5) residents. The facility currently has (4) non-ambulatory residents, who are residing in the facility. There are (2) residents diagnosed with mild Dementia residing in the facility. There are (2) Hospice resident at the facility. The facility does not handle residents’ cash resources.

LPA toured the facility. The facility consists of (4) resident bedrooms, (2) bathrooms, living room, dining room, kitchen. Residents bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Bathrooms are clean, sanitary, and fixtures are working properly, the bathrooms grab bars are secure and non-skid mats in place. The facility water temperature properly measured at 116 F°. Resident bath towels, toiletries, and personal hygiene supplies were adequately stocked. Common areas were clean and hazard free. All doorways were free of obstructions and have auditory alarms.

The kitchen is clean, sanitary, and observed to be within Title 22 regulations. The facility currently has a sufficient supply of perishable as well non-perishable food items. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors and Carbon monoxide detectors were tested and found to be operating properly. Outside grounds were toured and no bodies of water were observed. All walkways around the home were clear of hazards. Back patio area has a shaded porch and is used as main visiting point.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SOUTHWOODS LIVING, INC.	FACILITY NUMBER: 198320249
	VISIT DATE: 02/16/2023

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LPA observed a sign-in/sanitation station at the facility entry. There is hand sanitizer and masks around the facility. Facility has screening process for all visitors, sanitizer/soap, paper towels, and additional PPE supplies are stored inside the garage. The facility is prepared to provide a private room for isolation if needed. The facility mitigation plan was submitted to CCL on 02/03/2022.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed no deficiencies at the facility.

A copy of the liability insurance was provided to LPA.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the Tina Cinco/Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC809 (FAS) - (06/04)

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