198320454-9-26-2024-11-AS-SLEO-D9GQW9-20240926123134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320454
Report Date: 09/26/2024
Date Signed: 09/26/2024 12:31:43 PM

Document Has Been Signed on 09/26/2024 12:31 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	COGIR OF SOUTH BAY		FACILITY NUMBER:	198320454
ADMINISTRATOR:	HILES, LINDA		FACILITY TYPE:	740
ADDRESS:	21507 HAWTHORNE BLVD		TELEPHONE:	(213) 808-4531
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	34	CENSUS: 0	DATE:	09/26/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Adminstrator - Linda Hiles		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 09/26/2024, Licensing Program Analyst (LPA) Leandro conducted an announced visit to the facility for purpose of a pre-licensing evaluation. On 1/31/2024, an application was submitted to CCLD, for Initial license for a Residential Care Facility for the Elderly to serve adults ages 60 and over. The requested capacity is for 34 non-ambulatory residents of which 17 maybe bedridden. The facility is located on a main street. The facility is a residential building. The facility has: 17 apartments (each apartment has 1 to 2 bedrooms with closets, 1 full bathroom, 1 kitchen/dining/living room area, 1 utility closet with a washer and dryer), 1 multipurpose room (the room maybe used as the dining room and an activity room), 1 public restroom, outside spaces with shaded seating, 1 medication room, 1 office, and a main entrance lobby with front desk. LPA Leandro conducted a review of the Physical Plant, Apartments, Bathrooms, Supplies, Food Service, Medications, Records, Administration, Activities, Pe-Licensing Checklist and Component III Orientation. MEDICATIONS There is a locked centralized storage area for resident medications.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COGIR OF SOUTH BAY	FACILITY NUMBER: 198320454
	VISIT DATE: 09/26/2024

NARRATIVE

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PHYSICAL PLANT
Facility is clean, sanitary, and in good repair. Protective devices are in place to include nonslip material on rugs. Indoor and outdoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68 degrees and 85 degrees. Stairways, inclines, ramps, open porches, and areas of potential hazard are well-lit and equipped with sturdy hand railings. For facilities of 16 or more capacity there is a private office for the administrator, a reception area, and bathroom for visitors. For facilities of 16 or more capacity and facilities having separate floors or buildings without full time staff, there are signal systems in place. Fire Alarms and Smoke alarms operate properly. Carbon monoxide detectors operate properly.

APARTMENTS
Resident apartments are large enough to allow for easy passage and to accommodate furniture and assistive devices such as wheelchairs, walkers, or oxygen equipment. There is a dresser and closet space for each resident that includes at least two (2) drawers or eight (8) cubic feet of dresser space per resident. If applicable, resident bedrooms with security bars on windows/doors have at least one (1) window/door in the bedroom with an approved safety release to allow emergency evacuation.

FOOD SERVICE
Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0 degrees Fahrenheit. Refrigerator is a maximum of 45 degrees Fahrenheit. A seven (7) day supply of non-perishable food is present. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

RECORDS
There is confidential storage of personnel records at the facility. There is confidential storage of resident records at the facility.

POSTINGS
Mandated postings are posted.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COGIR OF SOUTH BAY	FACILITY NUMBER: 198320454
	VISIT DATE: 09/26/2024

NARRATIVE

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ACTIVITIES
For facilities of seven (7) or more capacity, an activities calendar is posted. There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to residents for visitors.

MISCELLANEOUS
There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. For facilities of 16 or more capacity, there is a designated laundry space. There are two operating telephones and a videoconferencing device available to residents. Emergency lighting and supplies to include flashlights with batteries. Vehicles used to transport residents are in safe operating condition.

COMPONENT III
Component III presentation was completed.

No plans of correction were provided.

LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to the applicant.

An exit interview was conducted, and a hard copy of this report was left with the Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

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