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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602887
Report Date: 03/22/2023
Date Signed: 03/22/2023 01:26:21 PM


Document Has Been Signed on 03/22/2023 01:26 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 ASSISTED LIVING OF HERMOSA BEACHFACILITY NUMBER:
198602887
ADMINISTRATOR:ERIC K MENSAHFACILITY TYPE:
740
ADDRESS:1837 PACIFIC COAST HWYTELEPHONE:
(310) 937-0959
CITY:HERMOSA BEACHSTATE: CAZIP CODE:
90254
CAPACITY:142CENSUS: 71DATE:
03/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Administrator Eric MensahTIME COMPLETED:
01:33 PM
NARRATIVE
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On 3/22/2023 Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced case management visit to the above facility. LPA Randle was greeted by Staff Administrator Eric Mensah and explained the purpose of the visit. LPA was granted entrance into the facility.

On 3/21/2023 LPA Randle spoke with Administrator Eric Mensah and Lenneor Folkes via telephone call. Facility staff requested information on how to obtain an exception. During the conversation, LPA Randle was told that the facility was retaining a resident with a prohibited health condition.

Deficiencies are being cited under California Code of Regulation Tittle 22; Division 6, Chapter 8 (see attached 809-D)



Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights provided to Administrator Eric Mensah
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah RandleTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
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


Document Has Been Signed on 03/22/2023 01:26 PM - It Cannot Be Edited

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: SUNRISE ASSISTED LIVING OF HERMOSA BEACH
FACILITY NUMBER: 198602887

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2023
Section Cited

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Prohibited Health Conditions
Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries.
This requirement is not met as evidenced by:
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POC: Administrator will submit an exception requestion with all accompanying documentation including in the plan if the resident's medical condition elevates; requires a higher level of care, , they will ensure the resident is relocated to a skilled-nursing facility (SNF) or hospital; and, the relocation will take place immediately.
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Based on telephone interview, the facility is retaining resident R1, who was diagnosed with an unstageable pressure injury. The poses a potential Persona Rights risk to residents in care.
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. This plan is due to CCLD/El Segundo ASC Office via fax by POC date.
Type B
03/22/2023
Section Cited

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Administrator - Qualifications and Duties
The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)…Knowledge of the requirements for providing care and supervision ....Knowledge of and ability to conform to the applicable laws, rules and regulations........

This requirement is not met as evidenced by:
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POC: Administrator shall review the cited section and shall write a written self-certification to adhere to the regulation. POC shall be submitted via fax to CCLD office by POC due date.
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Based on interview, the administrator failed to adhere to Title 22 regulations and failed to timely request an exception for a prohibited health condition. This violation poses a potential health and safety to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah RandleTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2