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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602190
Report Date: 09/25/2024
Date Signed: 09/25/2024 04:58:20 PM

Document Has Been Signed on 09/25/2024 04:58 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:CASA DEL SOL RESIDENCEFACILITY NUMBER:
198602190
ADMINISTRATOR/
DIRECTOR:
JACOBS, DOV EFACILITY TYPE:
740
ADDRESS:11606 11602 W WASHINGTON BLVDTELEPHONE:
(323) 678-4426
CITY:CULVER CITYSTATE: CAZIP CODE:
90066
CAPACITY: 12CENSUS: 3DATE:
09/25/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Vida M. ZelayaTIME VISIT/
INSPECTION COMPLETED:
04:58 PM
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Licensing Program Analyst (LPA) Troy Watson conducted an unannounced visit to Casa Del Sol on 09/25/2024 at 08:52 AM. The LPA met with the Administrator Vida Zelaya and the purpose of the visit was explained. The facility is licensed to serve 12 non-ambulatory residents and currently has a census of (3). The facility does not handle any of the resident’s money.

This home is a one-story home consisting of: (3) resident bedrooms, (3) bathrooms, (1) living room, (1) kitchen with a dining room, living room area, and laundry area located in the back of the facility a shaded patio area located outside the facility’. The resident’s bedrooms had the required furniture, lamps, adequate bed linen and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked and found to be sanitary and within Title 22 regulations. Toilets flushed and water faucets worked properly, grab bars were secure, showers were free of mold and mildew. The water temperature measured between 118 F in each bathroom. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas such as the dining room and living room were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supplies were checked and adequately stocked. All cleaning solutions, hazardous items, and medications were in a securely locked space that will be inaccessible to residents. Five out of (5) smoke detectors / carbon monoxide detectors worked properly. The residence has (1) fire extinguisher that was inspected on 09/25/24 and is fully charged. The First Aid kits were checked and properly stocked with scissors, tape, gauze, and certified manual. No bodies of water were observed around the facility. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

An exit interview was conducted, and a copy of this report was provided to the LVN Medication Nurse Vida M. Zelaya.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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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