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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602549
Report Date: 01/26/2023
Date Signed: 01/26/2023 01:12:29 PM


Document Has Been Signed on 01/26/2023 01:12 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:SUNRISE AT PALOS VERDESFACILITY NUMBER:
198602549
ADMINISTRATOR:KELLY JACOBSFACILITY TYPE:
740
ADDRESS:25535 HAWTHORNE BLVDTELEPHONE:
(310) 377-7425
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:115CENSUS: 76DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Kelly Koul AdministratorTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Kelley Koul Administrator and the purpose of today’s visit was explained.

There are currently (76) residents in the facility. The facility is a five-Level y structure located in a mixed use neighborhood. 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.

LPA and Administrator toured the entire facility inside and out. Documents are posted as mandated. Bedrooms contain the mandated furniture. The bathrooms have grab bars and non-skid mats and are clean and operational. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Residents files reviewed are current along with medications are current. Staff files reviewed are current. Ample supply of perishable and nonperishable food, hot water temperature is within Title 22 limits, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, fire extinguishers are fully charged. Exit, walkways and/or passageways, facility grounds are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors and temperatures are logged and checked. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed). Facility trash cans are covered with lids, Facility has 30 days of PPE’s, and a mitigation plan. Fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & IPAD for residents to use, resident’s temperatures are checked and logged per CDC guidance. Emergency contacts are updated. PPE's are enough for 30 days. All residents and staff are vaccinated and boosted

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator and a hard copy of report provided.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah RandleTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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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