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Department of
SOCIAL SERVICES
Community Care Licensing
COMPLAINT INVESTIGATION REPORT
Facility Number:
198602227
Report Date:
02/03/2023
Date Signed:
05/02/2023 09:20:23 AM
Unsubstantiated
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO
,
1000 CORPORATE DR #100
MONTEREY PARK
,
CA
91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2022
and conducted by Evaluator
Jeremiah Randle
PUBLIC
COMPLAINT CONTROL NUMBER:
11-AS-20220919210318
FACILITY NAME:
ASAHI RESIDENTIAL CARE
FACILITY NUMBER:
198602227
ADMINISTRATOR:
LACANILAO, EDNA
FACILITY TYPE:
740
ADDRESS:
18527 DORMAN AVE
TELEPHONE:
(310) 327-1633
CITY:
TORRANCE
STATE:
CA
ZIP CODE:
90504
CAPACITY:
6
CENSUS:
4
DATE:
02/03/2023
UNANNOUNCED
TIME BEGAN:
09:55 AM
MET WITH:
Administrator Edna Lacanilao
TIME COMPLETED:
05:11 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Created in error
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Created in error
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME:
Stephanie Cifuentes
TELEPHONE:
(661) 644-7743
LICENSING EVALUATOR NAME:
Jeremiah Randle
TELEPHONE:
(323) 213-1116
LICENSING EVALUATOR SIGNATURE:
DATE:
02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099
(FAS) - (06/04)
Page:
1
of
5
Control Number
11-AS-20220919210318
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO
,
1000 CORPORATE DR #100
MONTEREY PARK
,
CA
91754
FACILITY NAME:
ASAHI RESIDENTIAL CARE
FACILITY NUMBER:
198602227
VISIT DATE:
02/03/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Created in error
SUPERVISOR'S NAME:
Stephanie Cifuentes
TELEPHONE:
(661) 644-7743
LICENSING EVALUATOR NAME:
Jeremiah Randle
TELEPHONE:
(323) 213-1116
LICENSING EVALUATOR SIGNATURE:
DATE:
02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/03/2023
LIC9099
(FAS) - (06/04)
Page:
2
of
5
Control Number
11-AS-20220919210318
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO
,
1000 CORPORATE DR #100
MONTEREY PARK
,
CA
91754
FACILITY NAME:
ASAHI RESIDENTIAL CARE
FACILITY NUMBER:
198602227
VISIT DATE:
02/03/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Created in error
SUPERVISOR'S NAME:
Stephanie Cifuentes
TELEPHONE:
(661) 644-7743
LICENSING EVALUATOR NAME:
Jeremiah Randle
TELEPHONE:
(323) 213-1116
LICENSING EVALUATOR SIGNATURE:
DATE:
02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/03/2023
LIC9099
(FAS) - (06/04)
Page:
3
of
5
Control Number
11-AS-20220919210318
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO
,
1000 CORPORATE DR #100
MONTEREY PARK
,
CA
91754
FACILITY NAME:
ASAHI RESIDENTIAL CARE
FACILITY NUMBER:
198602227
VISIT DATE:
02/03/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Created in error
SUPERVISOR'S NAME:
Stephanie Cifuentes
TELEPHONE:
(661) 644-7743
LICENSING EVALUATOR NAME:
Jeremiah Randle
TELEPHONE:
(323) 213-1116
LICENSING EVALUATOR SIGNATURE:
DATE:
02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/03/2023
LIC9099
(FAS) - (06/04)
Page:
4
of
5
Control Number
11-AS-20220919210318
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO
,
1000 CORPORATE DR #100
MONTEREY PARK
,
CA
91754
FACILITY NAME:
ASAHI RESIDENTIAL CARE
FACILITY NUMBER:
198602227
VISIT DATE:
02/03/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Created in error
SUPERVISOR'S NAME:
Stephanie Cifuentes
TELEPHONE:
(661) 644-7743
LICENSING EVALUATOR NAME:
Jeremiah Randle
TELEPHONE:
(323) 213-1116
LICENSING EVALUATOR SIGNATURE:
DATE:
02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/03/2023
LIC9099
(FAS) - (06/04)
Page:
5
of
5