198602227-10-27-2023-11-AS-WGIS-CWZQNF-20231027121904

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602227
Report Date: 10/27/2023
Date Signed: 10/27/2023 12:19:29 PM

Document Has Been Signed on 10/27/2023 12:19 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ASAHI RESIDENTIAL CARE		FACILITY NUMBER:	198602227
ADMINISTRATOR:	KRISTINA FATIMA LACANILAO		FACILITY TYPE:	740
ADDRESS:	18527 DORMAN AVE		TELEPHONE:	(310) 327-1633
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 5	DATE:	10/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:			TIME COMPLETED:	12:30 PM

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	On 10/27/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. During today's visit LPA met with House Manager, Kristina Lacanilao , and explained the purpose of today's visit. The facility is serves clients age 60 and over, is approved for six non-ambulatory, two of which may be bedridden and a hospice waiver of 3. Currently there are 5 residents residing in the facility. Physical Plant/Structure The facility is a single-story home in a residential neighborhood. The home consists of five bedrooms , two bathrooms, living room, dining room, kitchen, front yard, backyard, and garage. LPA toured the facility and found it to be in good repair. The front and backyard are landscaped and maintained. LPA observed a shaded patio in the backyard with table and chairs. All ramp railings are secured. All walkways outside were observed clean, clear, and free of debris, hazards and obstructions. LPA did not observe any bodies of water on the property. Bedrooms LPA inspected all bedrooms and found them to be clean and in good repair. LPA observed the rooms to have the required items including a bed(s), dresser(s), chair(s), nightstand, and storage space for resident's personal belongings. All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of linens in a cabinet in the the hallway in good repair. All rooms had were observed to have ample lighting. Bathrooms LPA inspected all bathrooms and found them to be clean and operational. Showers were observed to have nonskid matts and shower chairs available. The safety hand rails were securely fastened. LPA observed an ample supply of hygiene products stored in a cabinet under the counter and are inaccessible to residents. Cleaning products were observed secured in a locked cabinet under the sink. LPA observed an ample supply of towels stored in a cabinet in the bathrooms. The water temperature measured 114.6- and 116.2-degrees Fahrenheit. Kitchen LPA inspected the kitchen and found it to be clean and sanitary. All appliances were observed in good working repair.LPA observed an ample supply of cutleries, pots, and pans in good repair. Continued on LIC809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ASAHI RESIDENTIAL CARE	FACILITY NUMBER: 198602227
	VISIT DATE: 10/27/2023

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LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods. All food was observed properly stored and dated. Sharps were observed in a secured locked drawer in the kitchen and are inaccessible to residents. Cleaning products were observed secured in a locked cabinet under the kitchen sink. The water temperature measured 112.4-degrees Fahrenheit.
Common Rooms LPA inspected all common room and observed them to clean and in good repair. The living room has two couches and a recliner to accommodate all residents. There is a large table available for activities. The dining room has a large rectangle table and chairs to accommodate all residents. All walkways and hallways were observed to be clean, clear, and free of hazards and obstructions. All rooms were observed to have ample lighting. The facility was maintained at a comfortable temperature.
Medications All Centrally Stored Medications were observed in a locked cabinet in the hall way and are inaccessible to residents. LPA reviewed the medications and MAR for two residents and found them to be consistent with properly documented records.
Files and Interviews LPA reviewed all five residents files and found they contained required document. LPA interviewed all residents and all were happy with the service and care they receive from staff. LPA reviewed the Administrator and three staff files and found they contained the required training, certification, and clearance. Staff training are done on Relias and each staff completes 20-hours of training annually. LPA interviewed the two staff who were present during the inspection and both staff were able to answer questions regarding policy, and resident care and rights.
Safety LPA observed all required postings on a board near the entrance. LPA observed a fully charged fire extinguisher mounted in the hallway last serviced on 09/11/23. The last inspection and fire sprinkler service was conducted by the local fire department on 04/06/23. All smoke and carbon monoxide detectors were in compliance and operational. The last emergency drill was conducted on 09/15/23. LPA inspected the First Aid kit and found it contained the required items and a manual. All doors in the facility sound when they are opened to notify staff. All gates on the side of the home are easily accessible for an exit.
Infection Control LPA observed a visitor log and Covid-19 screening upon entry. LPA observed multiple sanitizing stations throughout the facility. LPA observed a 30- supply of PPE. All Infection Control signs were observed posted.
According to the California Code of Regulations (Tittle 22, Division 6, Chapter 8) LPA did not observe or cite any deficiencies.
An exit interview was conducted with House Manager Kristina Lacanilao, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC809 (FAS) - (06/04)

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