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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602191
Report Date: 09/05/2023
Date Signed: 09/05/2023 04:24:33 PM


Document Has Been Signed on 09/05/2023 04:24 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:CASA DEL SOL II RESIDENCEFACILITY NUMBER:
198602191
ADMINISTRATOR:YCHEAL D. LEVINEFACILITY TYPE:
740
ADDRESS:11600 W WASHINGTON BLVDTELEPHONE:
(310) 390-9045
CITY:CULVER CITYSTATE: CAZIP CODE:
90066
CAPACITY:6CENSUS: 1DATE:
09/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:19 PM
MET WITH:Hanson ValorieTIME COMPLETED:
04:35 PM
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On 09/05/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced visit to Casa Del Sol II Residence. The purpose of today’s visit was to conduct the annual inspection. LPA met with Head Nurse, Valorie Hanson. The facility is licensed for 6 non-ambulatory residents. The facility currently has (1) ambulatory residents. LPA Richard and Nurse Hanson toured the physical plant and reviewed staff and resident records.

Upon entrance is dining room area and table. This facility has two levels. Level one has 5 bedrooms and 5 bathrooms. There is a linen storage closet and one shower room located in the center of the facility for all residents to share. The rooms on level 2 are used as offices for staff. The facility conducted a fire drill on 05/23/2023. The hot water temperature tested 119.7F degrees.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate residents comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Food and meals are prepared in the main kitchen located in the skilled nursing facility and is brought to the residents on carts. Staff provided LPA with a waiver. The All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CASA DEL SOL II RESIDENCE
FACILITY NUMBER: 198602191
VISIT DATE: 09/05/2023
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Carbon monoxide detector was operational. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

During the visit, LPA did not observed the facility infection control practices. LPA observed a screening station with sanitizer in the facility entrance and additional sanitation supplies in nursing office inaccessible to the residents. LPA observed staff wearing mask. Each resident has their own individual room for isolation and required postings are throughout the facility.

No deficiencies cited during this visit. Exit interview conducted and a copy of this report was given to Valorie Henson at the time of the visit.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC809 (FAS) - (06/04)
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