198320495-10-25-2024-11-AS-RCLD-DADPEB-20241025111452

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320495
Report Date: 10/25/2024
Date Signed: 10/25/2024 11:15:52 AM

Document Has Been Signed on 10/25/2024 11:15 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	LOVING ARMS SOUTH BAY I		FACILITY NUMBER:	198320495
ADMINISTRATOR/ DIRECTOR:	MACANDILI, EDJESKA		FACILITY TYPE:	740
ADDRESS:	1637 W 228TH ST		TELEPHONE:	(714) 305-2110
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 6		CENSUS: 0	DATE:	10/25/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:06 AM
MET WITH:	Edjeska Macandili		TIME VISIT/ INSPECTION COMPLETED:	11:30 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	Licensing Program Analyst (LPA), Regina Cloyd, conducted an announced visit to the facility for purpose of a prelicensing evaluation. An application was submitted to CCLD for initial license for a Residential Care Facility for the Elderly to serve the Elderly for ages 60 years and older. The requested capacity is for six non-ambulatory. Structure: Facility is a (4) four resident bedroom, (2) two-bathroom, single story house with a separate storage unit. The facility is a grey stucco structure with a living room, dining room, kitchen, and laundry area. There is a large, backyard patio area and front yard parking on the premises. The outdoor passageway is free from obstructions. Bedrooms Residents: All bedrooms are for non-ambulatory residents. Bedroom #3 and #4 has two beds, two chairs, two night stands, and two lamps in addition to overhead lighting. There are two dressers with four drawers, which comply with the requirement of 8 cubic feet of space. Bathrooms: All bathrooms have a working toilet, wash basin, and showers. There are two bathrooms that will accommodate non-ambulatory residents in a wheel chair. Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

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: LOVING ARMS SOUTH BAY I	FACILITY NUMBER: 198320495
	VISIT DATE: 10/25/2024

NARRATIVE

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Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in cabinet in the dining room.

Emergency Phone Numbers, Exit Plan & Menu:
The Emergency Disaster Plan with emergency phone numbers are posted & readily available for review in the kitchen on the cork board. The facility sketch and exit plan is located in the living room. Fire extinguisher located in the kitchen mounted on wall and a second (unmounted) extinguisher is located next to it.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer next to the stove. Emergency food is stored in the pantry and the facility has a minimum of one week of non-perishables and a minimum of two days of perishables.

Smoke Detectors:
Smoke and carbon monoxide detectors are operable and interconnected.

Appliances:
Stove burners, oven, microwave, and washer are working. There is one refrigerator in the kitchen. The refrigerator has a measured temperature of at least 40 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat. Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

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: LOVING ARMS SOUTH BAY I	FACILITY NUMBER: 198320495
	VISIT DATE: 10/25/2024

NARRATIVE

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Toxins:
Locked and stored under the sink.

Medications, First-Aid Kit & Book:

A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in a cabinet in the kitchen, available for staff use but inaccessible to residents.

Residents & Staff Files:
Records of staff and residents will be stored in a locked cabinet in the dining room area.

Reading Material, Games, Equipment & Materials:
The facility has arts and crafts, crossword puzzles, and sketch pads for the residents' use.

Fire clearance:
Fire Clearance with an approval of delayed egress or delayed egress with secured (locked) perimeter was approved on 09/20/24. The facility exits do not currently contain delayed egress but sensory signals. The facility has a fence with five self-latching gates plus two manual gates around the parking lot.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.
Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: LOVING ARMS SOUTH BAY I	FACILITY NUMBER: 198320495
	VISIT DATE: 10/25/2024

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During the prelicensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected and proof of correction shall be submitted to the CCLD office to the attention of LPA Regina Cloyd by 11/12/2024. 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. Provide general liability insurance.
2. Post a warning sign in a prominent area for taps delivering water at 125 degrees or above (bathroom near the dining room).
3. Purchase a dryer.
4. Make backyard exit ramp ADA compliant.
5. Secure an active telephone line for the facility.
6. Enlarge Residential Care Facility for the Elderly Complaint Poster to 20” x 26”.
7. Install a shaded umbrella/item over outdoor furniture.
8. Repair bottom portion of the refrigerator.
9. Update LIC610E with portable generator suppliers.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA Cloyd 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.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

LIC809 (FAS) - (06/04)

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