<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320277
Report Date: 07/27/2023
Date Signed: 08/09/2023 01:01:11 PM


Document Has Been Signed on 08/09/2023 01:01 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:LEGACY VILLA SENIOR CAREFACILITY NUMBER:
198320277
ADMINISTRATOR:CLARKE, STEPHENFACILITY TYPE:
740
ADDRESS:21012 DOBLE AVENUETELEPHONE:
(310) 418-7938
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY:6CENSUS: 4DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Stephen ClarkeTIME COMPLETED:
11:40 AM
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 7/27/23, Licensing Program Analyst (LPA) Felisa Shirley arrived to conduct an unannounced Annual required visit with a primary focus on infection control measures, using the new Care Inspection Tool. LPA was met by Joel Morales, Supervisor, and the purpose of today’s visit was explained.

LPA was not able to complete inspection due to time restraints, nor review files for Staff and Residents. LPA will come back at a later date to complete Annual.

The following documents were requested and received during the visit: (LPA was not able to review)

· Staff Records


No deficiencies were cited during this visit.

An exit interview was conducted with Joel Morales and a hard copy of the report was provided.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa ShirleyTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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 1