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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602227
Report Date: 11/07/2024
Date Signed: 11/07/2024 04:24:28 PM

Document Has Been Signed on 11/07/2024 04:24 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 CAREFACILITY NUMBER:
198602227
ADMINISTRATOR/
DIRECTOR:		KRISTINA FATIMA LACANILAOFACILITY TYPE:
740
ADDRESS:18527 DORMAN AVETELEPHONE:
(310) 327-1633
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:22 PM
MET WITH:Kristina LacanilaoTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 11/07/24, the department conducted an unannounced annual visit to the facility listed above. During today's visit the department met with Administrator, Kristina Lacanilao, and explained the purpose of today's visit. The facility is licensed to serve six (6) non-ambulatory residents aged 60 and over, two of which may be bedridden and has an approved hospice waiver for three (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. The front and backyard are landscaped and maintained. The department 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. The department did not observe any bodies of water on the property.
Bedrooms The department inspected all bedrooms and found them to be clean and in good repair. The department observed all bedrooms to have the required furniture including a bed(s), dresser(s), chair(s), nightstand, and storage space for resident's personal belongings. All beds were observed with the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. The department observed an ample supply of linens in a cabinet in the hallway in good repair. All rooms were observed to have ample lighting.
Eva M AlvarezTELEPHONE: (323) 981-1755
Wendy GibbsTELEPHONE: (323) 981-1755
DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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: 11/07/2024
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Bathrooms The department inspected the bathrooms in the facility. All bathrooms were found to meet Title 22 regulations. Showers had secured safety handrails, nonskid mats, and shower chairs available. The department observed an ample supply of hygiene products stored in a cabinet under the bathroom counter and are inaccessible to residents. Cleaning products were observed secured in a locked cabinet under the bathroom sink. The department observed an ample supply of towels stored in a cabinet in the hallway. The water temperature measured 115.3- degrees and 116.1-degrees Fahrenheit.
Kitchen The department inspected the kitchen and found it to be clean and sanitary. All appliances were observed in good working repair. The department observed an ample supply of cutleries, dishware, and cookware in good repair. The department observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods properly labeled, dated, and packaged. Sharps and knives 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 and are inaccessible to resident. The water temperature measured 111.7-degrees Fahrenheit.
Common Rooms During the time of visit the facility was appropriately furnished. The department 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 in the dining room to accommodate all residents. All walkways and hallways in the home 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.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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: 11/07/2024
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Medications The department observed Centrally Stored Medications in a locked cabinet in the hallway and are inaccessible to residents. All medications were observed in their original packaging. The department reviewed the medications and Medication Administration Record (MAR) for five (5) residents and found them to be consistent with properly documented records.
Files The department reviewed five (5) resident files and found they contained required documents. The department reviewed the Administrator and three staff files and found they contained the required training, certification, and documents. Staff training is conducted on Relias and each staff completes 20-hours of training annually. Licensing fees are current.
Safety The department observed a fully charged fire extinguisher mounted in the hallway last serviced on 08/06/24. The last inspection and fire sprinkler service was conducted by the local fire department on 11/01/24. All smoke and carbon monoxide detectors were in compliance and operational. The last emergency drill was conducted on 10/10/24. The department inspected the First Aid kit and found it contained the required items and a current manual. The facility has a working landline telephone.
Infection Control The department observed a sanitizing station in the entry with hand sanitizer, face masks, a thermometer, and visitor log. The department observed a 30- supply of Personal Protective Equipment (PPE). All Infection Control signs were observed posted.
According to the California Code of Regulations (Tittle 22, Division 6, Chapter 8) the department did not observe or cite any deficiencies.
An exit interview was conducted with Administrator Kristina Lacanilao, and a copy of this report was provided.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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