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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602377
Report Date: 05/01/2023
Date Signed: 05/01/2023 01:10:42 PM


Document Has Been Signed on 05/01/2023 01:10 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:FAMILY CONNECT MEMORY CARE INCFACILITY NUMBER:
198602377
ADMINISTRATOR:SPIGLANIN, LAUREN MAHAKIANFACILITY TYPE:
740
ADDRESS:1747 GREENWOOD AVENUETELEPHONE:
(310) 383-1877
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 6DATE:
05/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:kristine simonianTIME COMPLETED:
01:30 PM
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On 05/01/2023 Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA Antonine Richard met with Administrator kristine Simonian and explained the purpose of today's visit. The facility is licensed to operate for six (6) residents ages 60 and over of which one (6) maybe non-ambulatory. The facility is approved for Three (3) hospice residents.


The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, two (2) bathrooms, living area, dining area, kitchen, and outside covered patio area.

LPA Antonine toured the inside and outside grounds of the facility with administrator Kristine. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 107.8F degrees. A comfortable temperature was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide. The facility liability insurance is current.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: FAMILY CONNECT MEMORY CARE INC
FACILITY NUMBER: 198602377
VISIT DATE: 05/01/2023
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for residents, staff and visitors, and sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-days supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

An exit interview held. A copy of this report was provided to administrator Kristine Simonian
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC809 (FAS) - (06/04)
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