198602191-9-1-2021-11-AS-JJOS-C6FTZU-20210901151054

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602191
Report Date: 09/01/2021
Date Signed: 09/01/2021 09:42:08 PM

Document Has Been Signed on 09/01/2021 09:42 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	CASA DEL SOL II RESIDENCE		FACILITY NUMBER:	198602191
ADMINISTRATOR:	YCHEAL D. LEVINE		FACILITY TYPE:	740
ADDRESS:	11600 W WASHINGTON BLVD		TELEPHONE:	(310) 390-9045
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90066
CAPACITY: 6		CENSUS: 3	DATE:	09/01/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Valorie Hansen, Head Nurse		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Jones 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 3 ambulatory residents. LPA Jones 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 08/16/2021.

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. LPA was unable to tour kitchen due to covid 19 restrictions. 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. 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.

Cont C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jennifer Jones
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DEL SOL II RESIDENCE	FACILITY NUMBER: 198602191
	VISIT DATE: 09/01/2021

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During the visit, LPA 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 a sign in sheet and temperature log for visitors. LPA's temperature was checked during the visit. LPA observed staff wearing mask. Each resident has their own individual room for isolation and required postings are throughout the facility. Staff advised LPA that visitors can meet with residents with an appointment.

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.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jennifer Jones
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

LIC809 (FAS) - (06/04)

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