198602887-5-22-2025-11-AS-PBUR-DGWKV6-20250522081346

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602887
Report Date: 05/21/2025
Date Signed: 05/22/2025 08:14:03 AM

Document Has Been Signed on 05/22/2025 08:14 AM - 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SUNRISE ASSISTED LIVING OF HERMOSA BEACH		FACILITY NUMBER:	198602887
ADMINISTRATOR/ DIRECTOR:	ERIC K MENSAH		FACILITY TYPE:	740
ADDRESS:	1837 PACIFIC COAST HWY		TELEPHONE:	(310) 937-0959
CITY:	HERMOSA BEACH	STATE: CA	ZIP CODE:	90254
CAPACITY: 142	TOTAL ENROLLED CHILDREN: 0	CENSUS: 77	DATE:	05/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Anita Csukardi		TIME VISIT/ INSPECTION COMPLETED:	04:00 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	Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced annual required visit with the primary focus on infection control measures and using the new CARE Inspection Tool. LPA Bunker met with Executive Director Anita Csukardi to explain the purpose of today's annual inspection. There are currently seventy-seven residents in placement. The facility's annual fees are current. The following 12 Domains will be observed and reviewed: Infection Control, Operational Requirements, Physical Plant & Environmental Safety, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/Incident Reports, Disaster Preparedness, and Residents with Special Health Needs. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." Ms. Csukardi and LPA Bunker toured the facility. The facility is a two-story building located in a commercial business area. It consists of a Memory Care Unit on the first floor with 15 apartment suites each, with its own bathroom, and an Assisted Living Unit on the second floor with 65 apartment suites, also with private bathrooms. The facility includes the following amenities and areas: a receptionist area, lobby, discovery room, bistro, reading area, parlor, living rooms, dining rooms, kitchens, a coordinator's office, mechanical closet, 4 public restrooms, life skills room, hair salon, Bathtique, activity room, Wellness office, and 3 laundry rooms, Additional features include a parking garage and an indoor/outdoor activity area with a shaded patio furnished with tables and chairs. See continued LIC809-C page 2

Stephanie Cifuentes	TELEPHONE: (323) 981-1755
Pamela Bunker	TELEPHONE: (323) 981-1755
	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNRISE ASSISTED LIVING OF HERMOSA BEACH	FACILITY NUMBER: 198602887
	VISIT DATE: 05/21/2025

NARRATIVE

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Continued LIC809-C page 2

Documents have been posted, as mandated, on the bulletin board in the lobby area. The following Title 22 regulated areas were audited and found to be in compliance: The facility telephones are working. Bedrooms: The apartment suites meet the required standards for furniture, safety, privacy, and comfort. Bathrooms: The bathrooms are clean and operational, and residents are provided with the necessary personal accommodations with non-skid surface mats ensuring safety and privacy. Linen and Supply: The facility has an adequate supply of linen. Kitchen and Food Service: The kitchen is adequately equipped for food preparation and service. A review of the food service revealed an ample supply of perishable and nonperishable food, stored appropriately.
Medication Storage and Management: Medications are centrally stored in a locked Med Cart on each floor with up-to-date records, ensuring proper storage and documentation. Common Areas: The Living rooms, dining rooms, and common areas are well-maintained, free of potential hazards, and meet the cleanliness standards necessary for the safety and well-being of residents. Safety Equipment and Measures: The facility is equipped with fully stocked first aid kits with manuals, functional hardwired, smoke and carbon monoxide detectors, and the fire extinguishers are compliant and have been properly charged. The hot water temperature is measured at 113.3 degrees and is maintained within the standard range of 105-120 degrees Fahrenheit. Emergency Preparedness: All exit doors are in compliance, the resident's bedroom windows are equipped with sliding window locks without thumbscrews, and the facility conducted a fire drill on May 08, 2025. Environmental Safety: The yard is free from debris and hazards, trash cans are covered, and no firearms or bodies of water are present on the premises. Hazardous items are kept inaccessible to residents. Staff Training: Staff members have received training on reporting dependent adult and elder abuse. Administrative Compliance: The Administrator Certificate is current and expires July 29, 2026, The HIV/TB requirements have also been verified.

See continued LIC809-C page 3

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNRISE ASSISTED LIVING OF HERMOSA BEACH	FACILITY NUMBER: 198602887
	VISIT DATE: 05/21/2025

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	Continued LIC9099-C page 3 A copy of the Facility Evaluation Report LIC809, and LIC809-Cs, was provided to Executive Director Anita Csukardi. There were no deficiencies cited. An exit interview was conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

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