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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600155
Report Date: 12/23/2022
Date Signed: 10/10/2023 05:35:34 PM

Document Has Been Signed on 10/10/2023 05:35 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SOUTHERN CALIFORNIA ASSISTED LIVINGFACILITY NUMBER:
198600155
ADMINISTRATOR:RYAN MAGNOFACILITY TYPE:
735
ADDRESS:1510 EDANRUTH AVENUETELEPHONE:
(626) 813-2552
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 6CENSUS: 6DATE:
12/23/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Administrator Rhea Ortiz-LuisTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Plan of Correction (POC) visit from subsequent annual visit conducted on 12/01/2022. LPA met with DSP Sir Ivan Sison and explained the reason for the visit. LPA was later joined by Administrator Rhea Ortiz-Luis.

During today’s visit LPA observed the following:

  • 3x4 cemented gap missing tile flooring in middle of client bathroom was repaired and new tile flooring was placed. LPA issued deficiency citing 80087(a) during the required annual visit on 12/01/2022, with a Plan of Correction (POC) due date of 12/15/2022. Administrator Ortiz-Luis claims she emailed LPA proof of new flooring in client bathroom, however, LPA did not receive such email prior to today’s visit nor a request for extension. Administrator Ortiz-Luis did send an email on 12/23/22 at 9:21am with a photo attachment of new tile flooring in client bathroom, after LPA arrived at the facility and observed the new flooring. LPA will assess civil penalties.
  • Construction debris including glass, bricks, and a folding table were observed by side of facility walkway. LPA issued deficiency citing 80087(c) during the required annual visit on 12/01/2022, with a POC due date of 12/15/2022. Administrator/Licensee did not correct deficiency nor submit proof of correction to this licensing agency by the POC due date. Folding table was moved to garage during the visit, glass and bricks were removed during visit. LPA will assess civil penalties.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2022
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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