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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601879
Report Date: 06/11/2021
Date Signed: 06/16/2021 09:31:22 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:KIZUNA ASSISTED LIVING 2FACILITY NUMBER:
198601879
ADMINISTRATOR:RAND S. TOJOFACILITY TYPE:
740
ADDRESS:18345 AMIE AVE.TELEPHONE:
3102143464
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY:6CENSUS: 1DATE:
06/11/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Ana Ailil ZunigaTIME COMPLETED:
02:15 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 06/11/21, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced Case Management visit for the Plan of Correction (POC). LPA Senaha informed Ana Ailil Zuniga the purpose of today’s visit was to ensure that the deficiency cited during the Annual visit dated 6/9/2021 was corrected and in compliance with Title 22 regulations.

LPA observed the following deficiency was corrected:
87465(a)(7) Based on observation and interview, the facility did not have a medication administration record.

LPA observed the Medications Records Administration (MARs) for resident (R1) on site. LPA interviewed resident (R1).

LPA Senaha will provide a Letter of Deficiency Citation cleared via email.

An exit interview was conducted and a copy of this report will be emailed to the Administrator.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don SenahaTELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
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