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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601962
Report Date: 01/27/2023
Date Signed: 01/27/2023 01:58:48 PM


Document Has Been Signed on 01/27/2023 01:58 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: 50DATE:
01/27/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator - Victoria Tran TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ashley Calderon, conducted an unannounced POC visit and upon arrival LPA met with Wellness Director Michelle Adams. Later met with Administrator Victoria Tran regarding citations issued on 05/23/22. The purpose of the visit was to inspect the facility to ensure the deficiencies cited were corrected and was discussed.

On today’s visit, LPA observed the following deficiencies have been corrected:
Section:87303 Maintenance and Operations, Due Date: 6/22/22.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.

During today's visit LPA Calderon collected staff and residents roster, Maintenance Request Log from April 28, 2022 - July 1, 2022. LPA along side with Victoria toured all three laundry rooms (Laundry room #1, #2 and #3) in the one single story building, outside perimeters and resident's rooms. LPA interviewed Administrator, Staff #1-#4 (S1-S4) and Residents #1-#5 (R1-R5). LPA observed clean laundry room and facility, operable laundry machines: washer and dryer, all knobs on laundry machines intact, flooring in laundry rooms in good repair, panels on laundry machines secured, and observed inoperable/ large trash items/ furniture and materials equipment on the side of the facility near staff parking/ next to trash bins ready for pick up from waste company. This area is inaccessible to residents in care and does not pose as a health and safety hazard. LPAs interviews with residents stated laundry room is in good repair, clean and all pathways are cleared. LPA's interviews with staff stated laundry machines or any facility repairs gets fixed, repaired or replaced in a timely matter. LPA reviewed Maintenance Log and laundry repair status were completed.

LPA Calderon cleared POC from deficiencies cited on 5/23/22 by LPA Nicol Wesley. LPA Calderon observed facility to be in good repair. No deficiencies were cited. LPA Calderon conducted the exit interview with Victoria Tran, a copy of this report LIC 809 and POC letter was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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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