198602549-2-15-2022-11-AS-DSEA-CBP5QT-20220215191005

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602549
Report Date: 02/15/2022
Date Signed: 02/15/2022 07:11:45 PM

Document Has Been Signed on 02/15/2022 07:11 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SUNRISE AT PALOS VERDES		FACILITY NUMBER:	198602549
ADMINISTRATOR:	KELLY JACOBS		FACILITY TYPE:	740
ADDRESS:	25535 HAWTHORNE BLVD		TELEPHONE:	(310) 377-7425
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	115	CENSUS: 67	DATE:	02/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Executive Director - Kelly		TIME COMPLETED:	03:45 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 02/15/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Executive Director Kelly Jacobs and explained the purpose of today’s visit. The facility is licensed to operate for one hundred and fifteen (115) non-ambulatory elderly residents ages 60 and above of which fifty (50) can be bedridden and approved for twenty (20) hospice. The facility is a five (5) story building structure, with ground floor being the parking and entrance, the first and second floors are Assisted Living, the third floor is terrace club (Memory Care) for residents and the fourth floor is reminiscence (Memory Care). There is a total of 37 Assisted Living units and 40 Memory Care units. LPA and Executive Director toured the physical plant. There were no bodies of water or obstructions on the premises. Various rooms were inspected – rooms 122, 123, 209, 221, 302, 316, 404 and 419 where beds and bedding supplies were in good condition, adequate lighting 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. Water temperature was measured and within Title 22 regulations between 106.7 F and 109.3 F. A comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. There is a walk-in refrigerator and freezer fully stocked in the kitchen. Food deliveries are made to the facility every Tuesday and Friday of every week. Multiple fire extinguishers were fully charged on each floor. Sprinkler system in place. Medication carts are located on each floor and was inspected. Laundry rooms exist on each floor for residents with laundry for big linen done in the laundry room on the first floor. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNRISE AT PALOS VERDES	FACILITY NUMBER: 198602549
	VISIT DATE: 02/15/2022

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

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a minimum 30-day supply of Personal Protective Equipment (PPE) available. All mandated inspection control posters were posted.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Executive Director Kelly Jacobs.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2