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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602887
Report Date: 04/19/2022
Date Signed: 04/19/2022 09:58:09 PM

Document Has Been Signed on 04/19/2022 09:58 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 ASSISTED LIVING OF HERMOSA BEACHFACILITY NUMBER:
198602887
ADMINISTRATOR:MORRIS, TRAVISFACILITY TYPE:
740
ADDRESS:1837 PACIFIC COAST HWYTELEPHONE:
(310) 937-0959
CITY:HERMOSA BEACHSTATE: CAZIP CODE:
90254
CAPACITY: 142CENSUS: 77DATE:
04/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Janelle Odishoo, AdministratorTIME COMPLETED:
01:40 PM
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On 4/19/22 at 11:00 AM, Licensing Program Analyst (LPA) Martessa Brown initiated a Case Management visit to the above facility. LPA met with Janelle Odishoo, Administrator and explained the purpose of today’s visit.

On 03/14/22, LPA received a faxed incident report and Death Report regarding Resident (R1) passing on 3/12/22.

On 4/19/22 LPA Brown met with the Administrator and conducted a case management regarding the above of incident. LPA interviewed the administrator and obtained the following documents: R1's admission agreement, physician reports, mars, appraisals, progress notes, emergency contact, LIC500 and resident roster. LPA was unable to interview staff members #1-2 due to being off.

On 4/19/22 LPA Brown toured the physical plant and conducted a health & safety check with the Lennora Folkes, Resident Care Director. LPA did not observe any deficiencies.

Due to additional information, more time is needed to investigate.

An exit interview was conducted with Janelle Odishoo.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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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