198601879-6-14-2024-11-AS-WGIS-D68VKM-20240614163035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601879
Report Date: 06/14/2024
Date Signed: 06/14/2024 04:30:43 PM

Document Has Been Signed on 06/14/2024 04:30 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:	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: 3	DATE:	06/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:42 PM
MET WITH:	Ana Tojo		TIME COMPLETED:	04:30 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 06/14/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Administrator, Ana Tojo, and explained the purpose of today’s visit. There are currently three (3) residents residing in the facility. Physical Plant/Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident’s rooms, 2 bathrooms, living room, dining area, kitchen, and outside patio area. LPA observed two (2) tables with umbrellas and chairs. LPA observed all walkways around the facility to be clean, clear, and free of obstructions, debris, or hazards. LPA did not observe any bodies of water on the premises. Bedrooms LPA inspected all resident rooms and observed the walls and floors to be in good repair. LPA observed all resident rooms had the required furniture including a bed, dresser, nightstand, storage space for personal belonging, and ample lighting. LPA observed all beds had the required linens including a mattress cover, fitted sheet, blanket, comforter, and pillows. LPA observed an ample supply of bed linens, and comforters at the time of visit. Bathrooms LPA inspected the facility bathrooms and found them to be within Title

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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: KIZUNA ASSISTED LIVING 2	FACILITY NUMBER: 198601879
	VISIT DATE: 06/14/2024

NARRATIVE

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22 regulations. All bathrooms were observed clean and operational. LPA observed storage area for personal hygiene products. LPA observed an ample supply of towels and personal hygiene products available for residents. All showers had a nonskid mat and secured safety handrails. The water temperature measured 116.6-degrees and 115.3-degrees Fahrenheit.
Kitchen LPA inspected the kitchen and observed it to be clean and sanitary. LPA observed all appliances to be operable and in good repair. LPA observed an ample supply of dishware, cookware, and cutleries. LPA observed a 2-day supply of perishable foods and a 7-day supply of non-perishable foods properly stored and labeled. The water temperature measured 106.6-degrees Fahrenheit. All sharps are secured in a locked drawer and are inaccessible to residents. All cleaning supplies are secured in a locked cabinet under the kitchen sink and are inaccessible to residents.
Common Rooms LPA observed the facility to be appropriately furnished during the time of visit. The facility has a living room with couches to accommodate all residents. The dining room table is large enough to accommodate residents for meals. LPA observed all walkways and hallways in the facility to be clean, clear, and free of hazards and obstructions. All rooms were observed with ample lighting. The facility was kept at a comfortable temperature.
Safety LPA observed a fully charged fire extinguisher located in the laundry room. All smoke and carbon monoxide detectors are operable. The last emergency drill was conducted on 04/03/24. The facility sketch is posted in the dining room of the
facility. The facility’s Emergency and Disaster Plan is posted in the dining room. LPA observed all required documents posted in the facility. The facility has a

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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: KIZUNA ASSISTED LIVING 2	FACILITY NUMBER: 198601879
	VISIT DATE: 06/14/2024

NARRATIVE

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working landline telephone. There are no firearms or ammunition stored at the facility.
Medication LPA observed all Centrally Stored Medications secured in a locked cabinet, in the garage, and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the medications and Medication Administration Record (MAR)for the three (3) residents. Three (3) out of three (3) resident’s MARs and medication are consistent with properly documented records.
Infection Control Upon entry, LPA observed a sanitizing station and visitor sign-in log on the counter. LPA observed on the counter there is hand sanitizer and masks available. LPA observed all required Infection Control signs posted in the facility. LPA observed a 30-day supply of Personal Protective Equipment (PPE).
File Review/Interviews LPA reviewed the files for the three (3) residents and observed they had the required documents. LPA interviewed two (2) residents, and both were happy with the care they receive at the facility. LPA reviewed the administrator and two (2) staff files and found they contained the required documents, certification, and training. The administrator’s Administrator Certificate is valid till 10/07/24. LPA interviewed two (2) staff, and all were able to answer questions regarding policy, procedure, and resident care and personal rights. During file review LPA observed the facility’s Licensing Fees are due on 06/25/24, LPA informed the Administrator.
LPA did not observe or cite any deficiencies.
An exit interview was conducted with Administrator, Ana Tojo, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC809 (FAS) - (06/04)

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