198603088-9-26-2023-11-AS-DESA-CW2W42-20230926165650

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603088
Report Date: 09/26/2023
Date Signed: 09/26/2023 04:56:57 PM

Document Has Been Signed on 09/26/2023 04:56 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:	AMALFI LIVING INC		FACILITY NUMBER:	198603088
ADMINISTRATOR:	TINY A LAYUG		FACILITY TYPE:	740
ADDRESS:	22620 MADISON ST		TELEPHONE:	(424) 328-0569
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	6	CENSUS: 6	DATE:	09/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator Tina Cinco		TIME COMPLETED:	05:00 PM

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On 09/26/2023 at 2:00 pm Licensing Program Analyst (LPA) David España conducted an unannounced required annual visit. Upon arriving at the facility, LPA met with Fidel Antonio, House Manager, and the Administrator Tina Cinco, who assisted with the visit. Upon arrival at the facility, LPA David España conducted a risk assessment at the front door. Based on the assessment, the facility is cleared of Covid-19 infection.
There are currently six (6) residents in the facility. The facility is a Residential Care Facilities for the Elderly (RCFE) licensed for six (6) and there are three (3) residents that are ambulatory and three (3) are non-ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of four (4) bedrooms, two (2) full bathrooms, and half (1/2) bath, shaded back yard, front yard, laundry room and attached two (2) car garage.

LPA and Fidel Antonio toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. Resident in bedroom 1 is on oxygen and appropriate sign is present the bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detectors 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 Medications and file are current.

Staff records were reviewed, 6 out of 6 staff (S1-6) records reviewed had current first aid certificates and had required criminal record clearances. Clients/Residents records were reviewed, 5 out of 5 client/residents records had Admission Agreements, Medical Assessments and Reappraisals; Preplacement Appraisal Information (LIC 603); Physicians Report (LIC 602) Medical assessment including TB test; Identification and Emergency Information (LIC 601); Consent for Medical Treatment (LIC 627C); Telecommunications Device Notification form (LIC 9158); Functional Capability Assessment (LIC 9172); Personal Rights Forms (LIC 613); and Centrally Stored Medications and Destruction Record (LIC 622) etc.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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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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: AMALFI LIVING INC	FACILITY NUMBER: 198603088
	VISIT DATE: 09/26/2023

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There is a two-day (2) supply of perishable and a seven-day (7) supply of non-perishable food, hot water temperature is 116 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 2 fire extinguishers were fully charged. First Aid kit complete and with Manual current. Exit, walkways and/or passageways, front and back yard 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 are logged, and temperature checked sanitizer/soap in the staff bathroom and additional sanitation supplies are locked in the garage. The resident’s temperatures are checked and logged once a day. PPEs are enough for 3 months.

According to the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, LPA did not observe any deficiencies, based on LPA observation, interviews conducted and record review, therefore no citations were issued at this time. Based on LPAs observations there were two (2) Technical Assistance provided today 09/26/2023.

Technical Assistance:

Resident Rights/Information - Technical Assistance: 87468(c)(2)(A)

Disaster Preparedness - Technical Assistance: 1569.695(a)(5)

An exit interview was conducted, Technical Assistance were reviewed and discussed with the Licensee Tina Cinco. A copy of this report and appeal rights were discussed with the Licensee Administrator Tina Cinco.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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