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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601962
Report Date: 05/10/2022
Date Signed: 05/10/2022 05:32:51 PM


Document Has Been Signed on 05/10/2022 05:32 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:SOUTHLAND LIVINGFACILITY NUMBER:
198601962
ADMINISTRATOR:TRAN, VICTORIAFACILITY TYPE:
740
ADDRESS:11701 STUDEBAKER ROADTELEPHONE:
(562) 406-7326
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:75CENSUS: 48DATE:
05/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Victoria TranTIME COMPLETED:
05:30 PM
NARRATIVE
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LPA Nicol Wesley conducted a case management inspection upon completing complaint visit #28-AS-20220506112905. LPA Wesley met with Administrator Victoria Tran and discussed the purpose for todays visit. During todays visit LPA toured the physical plant and observed the following deficiencies that are in need of correcting(See the attached LIC 809D)

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.


Exit interview conducted.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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Document Has Been Signed on 05/10/2022 05:32 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: SOUTHLAND LIVING
FACILITY NUMBER: 198601962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2022
Section Cited

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Maintenance and Operations
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement has not been met as evidence by: During todays visit, LPA
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Wesley observed several wooden pallets, older washers, bedframes, brown wrought iron gate, yellow iron fencing, old bedroom furniture, boxes, wood pieces, broken down work truck(tags expired 2020)....Which poses a potential health and safety risk for residents in care.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
LIC809 (FAS) - (06/04)
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