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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602227
Report Date: 05/12/2021
Date Signed: 05/17/2021 09:27:53 AM

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
MONTERY PARK, CA 91754
FACILITY NAME:ASAHI RESIDENTIAL CAREFACILITY NUMBER:
198602227
ADMINISTRATOR:MENESES, MARKFACILITY TYPE:
740
ADDRESS:18527 DORMAN AVETELEPHONE:
(310) 327-1633
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY:6CENSUS: 5DATE:
05/12/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Edna LacanilaoTIME COMPLETED:
10:45 AM
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On 05/12/21 at 9:20 am - 10:45 am Licensing Program Analyst( LPA) Ernand Dabuet initiated a Collateral visit at this facility. LPA met with Edna Lacanilao Administrator. LPA explained the purpose of this visit is to gather information regarding a current complaint about AMAZING PARADISE HOME CARE complaint number 11-AS-20210329112836,

The visit consisted of an interview with Edna Lacanilao and one (1) staff #1 (S1) who responsible for care and supervision for resident #1 (R1) who formally resided at Amazing Paradise Home Care. Details on the interview are documented on LIC 812 crossed reference with AMAZING PARADISE HOME CARE 197608233.

During the visit, LPA requested a copy of (R1's) service records and staff and resident roster for review.

An exit interview was conducted with Edna Lacnilao, and a hard copy was provided via email.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
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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