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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601962
Report Date: 01/26/2023
Date Signed: 01/26/2023 04:27:47 PM


Document Has Been Signed on 01/26/2023 04:27 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:SOUTHLAND LIVINGFACILITY NUMBER:
198601962
ADMINISTRATOR:TRAN, VICTORIAFACILITY TYPE:
740
ADDRESS:11701 STUDEBAKER ROADTELEPHONE:
(562) 406-7326
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:75CENSUS: 50DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Victoria Tran, AdministratorTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection with the focus of the infection control domain. LPA met with Administrator, Victoria Tran, who assisted with the visit. The facility is licensed to serve 75 non-ambulatory residents, of which 10 may be bedridden. The approved bedridden rooms are #2,#4 through #12. The hospice waiver is approved for 10 residents.

LPA toured the facility and observed the following:
* Visitors and Staff sign-ins are in the main building which is connected to the skilled nursing building. The assisted living side is located to the left of the building. Temperature and symptom checks are done at the main entry.
* Covid-19 signage are posted throughout the facility. Hand washing signs are posted in the bathrooms. Seats are blocked off to promote social distancing in common areas.
* The facility maintains at least 30 days of PPE supplies.
* Food supplies of 2 day perishable and a week of non-perishable are observed. The meals are cooked in the skilled nursing building and are brought over in covered carts to serve residents.
* Medications are centrally stored in the Medication Room. LPA reviewed 5 residents' medications and medications are being administered as prescribed.
* The fire extinguishers were last inspected on 2/10/22.
* Staff were observed wearing a face mask.
* Staff are cleaning/disinfectant at least once every shift.

There are no deficiencies issued today. The exit interview was held. A copy of this report was given to the Administrator.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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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