198320361-4-11-2023-11-AS-FSHY-CQSMZA-20230411100249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320361
Report Date: 04/11/2023
Date Signed: 04/11/2023 10:02:58 AM

Document Has Been Signed on 04/11/2023 10:02 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SUNRISE VISTA ASSISTED LIVING,LLC		FACILITY NUMBER:	198320361
ADMINISTRATOR:	HAUF, MARY		FACILITY TYPE:	740
ADDRESS:	3342 ARTESIA BLVD		TELEPHONE:	(657) 215-5615
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 0	DATE:	04/11/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:08 AM
MET WITH:	Mary Hauf		TIME COMPLETED:	10:15 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 April 11, 2023, Licensing Program Analyst (LPA) Felisa Shirley and Licensing Program Manager (LPM) Stephanie Cifuentes met with Mary Hauf and conducted an announced visit to the facility for the purpose of a prelicensing evaluation. The purpose of the visit was explained, and LPA Shirley was granted entry. The requested capacity is for six (6) non-ambulatory clients from ages 18 to 59 years old. The facility site is a one-story home in a residential area. A tour of the physical plant and surrounding grounds was conducted and the following observed: KITCHEN: There were three days of perishable and seven days of nonperishable food. The kitchen was equipped with sufficient dining and cook ware to accommodate a maximum capacity of six (6) clients. Appliances and fixtures appeared to be in good condition and were functional. The hot water delivered at 114 F. BEDROOMS: There were four (4) bedrooms designated for resident use, and (1) bedroom to be used for staff or residents. All bedrooms were furnished for single occupancy and included all required furnishings, linens and bedding. There were no visible hazards. BATHROOMS: There are three (3) full bathrooms. All bathrooms were properly supplied with hygiene items and had functional fixtures. Hot water averaged at 114F. COMMON AREAS: LPA Shirley observed 2 living rooms, both with couches and activities and one with a piano. The common areas included furnishing capable of accommodating a maximum capacity of 6 clients. There were no visible hazards. Continued on 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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: SUNRISE VISTA ASSISTED LIVING,LLC	FACILITY NUMBER: 198320361
	VISIT DATE: 04/11/2023

NARRATIVE

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LPA observed night lights in the hallways for safety at night. A first aid kit has been inspected and has at least the following: antiseptic, bandages, gauze and current first aid manual, which are stored in a locked cabinet and available for staff use but inaccessible to clients. LPA Shirley observed locked file cabinet where staff and client files will be stored. Two fire extinguishers were observed, one in the kitchen and one in the living room. Both were fully charged and operational. Facility has 7 interconnected and hardwired smoke detectors and two carbon monoxide detectors, all operational.

SURROUNDING GROUNDS: The property is fenced and there is a shaded patio area and furniture appropriate for outdoor use. Shaded patio has a jacuzzi with a locked cover. There were no visible immediate hazards.

On 4/11/2023 Component III was completed with the Applicant during the Pre-Licensing visit at Sunrise Vista Assisted Living LLC. Information was provided about how to operate the facility within substantial compliance.

During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; By the end of the visit the licensee indicated they shall modify or repair the following items by April 18, 2023 and submit proof of correction to the CCLD office to the attention of LPA Felisa Shirley. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. During pre-licensing inspection, LPA Shirley noted that there are only 5 beds on the premises and the facility is asking to be licensed for 6 residents. Licensee will put an additional bed in one of the rooms and notify LPA when they have made the correction.

An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA 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: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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