198601879-10-22-2023-11-AS-DESA-CWUQSD-20231022122523

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601879
Report Date: 10/22/2023
Date Signed: 10/22/2023 12:25:33 PM

Document Has Been Signed on 10/22/2023 12:25 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	KIZUNA ASSISTED LIVING 2		FACILITY NUMBER:	198601879
ADMINISTRATOR:	RAND S. TOJO		FACILITY TYPE:	740
ADDRESS:	18345 AMIE AVE.		TELEPHONE:	(310) 214-3464
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 4	DATE:	10/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:12 AM
MET WITH:	Administrator, Ana Ailil Tojo		TIME COMPLETED:	12:50 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 10/22/2023 at 8:00 am Licensing Program Analyst (LPA) David España conducted an unannounced 1-year Annual visit to the facility. Upon arriving at the facility, LPA met with Administrator, Ana Ailil Tojo who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections. LPA met with Administrator Ana Ailil Tojo and explained the purpose of today’s visit. LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. The Residential Care Facilities for the Elderly (RCFE) facility is licensed to serve six (6) non-ambulatory residents of which 2 may be bedridden, fire clearance approved for delayed egress. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (2) bathrooms, living area, dining area, kitchen, and outside patio area with table and umbrella.The medications observed locked in the staff office in a cabinet, the facility walls, paint, floors, curtains doors, windows and furniture are in good repair, the smoke detector system was tested and operable. The facility has a fully charged fire extinguisher, toxins are locked under the kitchen sink, and sharp objects are locked in the kitchen drawer, all walkways and passageways are cleared from obstruction. The smoke detectors and carbon monoxide were operable. There were no pools or bodies of water observed, all windows are in good repair, the facility does not have a fireplace, all bedrooms #1 thru 4 are furnished with one twin bed, one chair, one night stand, one dresser, has adequate closet space and lighting. The facility passageways are equipped with handrails, all facility windows have vertical blind coverings, all the mattress and bedsprings are in good repair. The facility has a sufficient amount of linens, all beds have required linen/supplies: pillowcase mattress pads, fitted sheets, blankets, and bedspreads, the entire facility including resident bedrooms have adequate lighting. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2023

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: KIZUNA ASSISTED LIVING 2	FACILITY NUMBER: 198601879
	VISIT DATE: 10/22/2023

NARRATIVE

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The emergency disaster plan and required postings are posted in the dining area on the wall. The facility has an adequate supply of games and activities for the residents, the facility has an ample supply of perishable and non-perishable food items. A fully stocked first aid kit, the facility has an emergency supply of food, and water located the staff office, resident files will be locked in the staff’s office. All kitchen appliances are working properly, the facility has a working telephone, the washer and dryer is located in the hallway, pantry's, cupboard, freezer, stove, microwave, refrigerator and counters are clean operable. The water temperature measured 113.5 F in the bathrooms. A comfortable temperature of 74 degrees was maintained in the facility. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly.

LPA reviewed MAR and medication for four (4) clients, medication is given per physician’s directions and centrally stored medication is kept in locked place.

LPA reviewed Three (4) Staff records, include direct care staff and supervision, have current first aid, staff first aid certification expires on: 05/01/2025, health screening, training hours, and Administrator Certificate for Ana Ailil Tojo expires on .

Three (3) Advisory Notes: Two (2) Technical Assistance and one (1) Technical Violation were issued, please see LIC9102-AN.

Physical Plant/Environmental Safety - Technical Violation: 87309(a)
Resident Rights/Information - Technical Assistance: 87468(c)(2)(A)
Disaster Preparedness - Technical Assistance: 1569.695(a)(5)

One (1) deficiency was cited during this inspection visit for not having the Administrator Recertification Requirements which must be posted and shall be maintained by the facility.

87407(a-f) Administrator Recertification Requirements

Deficiencies were observed during today’s visit, copy of this report and appeals rights was provided to facility representative, Administrator, Ana Ailil Tojo.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/22/2023 12:25 PM - It Cannot Be Edited

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: KIZUNA ASSISTED LIVING 2	FACILITY NUMBER: 198601879
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87407(a-f)

This requirement is not met as evidenced by: Administrators shall complete at least forty (40) classroom hours of continuing education during each two (2)-year certification period, including… To apply for recertification after the expiration date of the certificate, but within four (4) years of the certificate expiration date.. Administrator Certification Section…(f) Certificates not renewed within four (4) years of their expiration date shall not be renewed, restored, reissued or reinstated…
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above.This requirement was not met as evidence by: during an interview with the acting Administrator, it was revealed she needed to submit renewal to CCLD. This poses a potential health and safety risk to residents in care.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	The administrator will create a plan to ensure future compliance to Title 22 Regulation 87407(a-f) Administrator Recertification Requirements. Proof of correction will be submitted to the department via email at David.espana@dss.ca.gov.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2023

LIC809 (FAS) - (06/04)

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