<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603220
Report Date: 06/12/2024
Date Signed: 06/12/2024 03:12:19 PM


Document Has Been Signed on 06/12/2024 03:12 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:CITY VIEW LA, LLCFACILITY NUMBER:
198603220
ADMINISTRATOR:HIRSCH, RENAFACILITY TYPE:
740
ADDRESS:515 N LA BREA AVETELEPHONE:
(323) 938-2131
CITY:LOS ANGELESSTATE: CAZIP CODE:
90036
CAPACITY:166CENSUS: 101DATE:
06/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Marcia McKay/Wellness DirectorTIME COMPLETED:
03:11 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
On 6/12/2024, Licensing Program Analyst LPA Alfonso Iniguez conducted a Case Management visit to follow up on the incident between (R#1 and R#2) reported to the Regional Office on 6/10/24. LPA was greeted by Marcia McKay, Wellness Director, who explained that the purpose of the visit was to gather records.

On 6/10/24, the regional office received a phone call from the facility and reported that, approximately at 5:30 AM on 6/10/24, (S#1) walked into the activity room and saw (R#1) engaging in inappropriate activity with (R#2). (S#1) promptly intervened and separated the two residents.

The following documents were provided to LPA Iniguez during the visit:

*Copy of SRI dated 6/10/24.
*Copy of Staff Schedule for June 2024.
*Copy of Resident Roster.
*Copies of staff timecards dated 6/9/24 and 6/10/24.
*Copies of (R#1) and (R#2) complete file (admissions agreement, wellness assessment, LIC 602A, admissions orders, consent forms, LIC 603A, LIC 601, advance directives, Identification cards, LIC 613-C).
Missing Items:
*A copy of the video footage will be retrieved by the department by a later day.

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

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Marcia McKay / Wellness Director.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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 1