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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601962
Report Date: 01/19/2024
Date Signed: 01/23/2024 09:51:15 AM


Document Has Been Signed on 01/23/2024 09:51 AM - 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:
01/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Victoria TranTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Nicol Wesley conducted the unannounced annual inspection at the facility. LPA met with Wellness Director Michelle Adams, and later Administrator Victoria Tran and 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 conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed the 7 fire extinguishers to be fully charged and serviced. The water temperature was tested and measured 114.6 degrees F.
The Last fire drill was conducted on 01/17/24. LPA Wesley interviewed 6 residents and 5 staff. The smoke detectors/carbon monoxide detector are operable. The facility mitigation plan is on file.

There are no deficiencies cited per the California Code of Regulations, Title 22.

Exit interview conducted, and a copy of the report was given to Victoria Tran.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
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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