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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602227
Report Date: 06/09/2021
Date Signed: 06/10/2021 06:50:50 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:
06/09/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:EDNA LACANILAOTIME COMPLETED:
11:06 AM
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On 06/09/21 at 9:01 am - 11:06 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 VISTA DEL MAR SENIOR LIVING Complaint number 11-AS-20202110140829.

The visit consisted of an interview with Edna Lacanilao staff #1 (S1) who responsible for care and supervision for resident #1 (R1) who formally resided at Vista Del Mar Senior Living.. Details on the interview are documented on LIC 812 crossed reference with Vista Del Mar Senior Living 197608029.

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

An exit interview was conducted with Edna Lacanilao, 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: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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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