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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602934
Report Date: 09/17/2025
Date Signed: 09/17/2025 04:55:05 PM

Document Has Been Signed on 09/17/2025 04:55 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:AYRES RESIDENTIAL CARE HOME-CENTURY CITYFACILITY NUMBER:
197602934
ADMINISTRATOR/
DIRECTOR:		MICHAEL GABAIFACILITY TYPE:
740
ADDRESS:10363 CALVIN AVETELEPHONE:
(310) 475-6484
CITY:LOS ANGELESSTATE: CAZIP CODE:
90025
CAPACITY: 6; 6CENSUS: 6DATE:
09/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:23 PM
MET WITH:Lucy UmanaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 09/17/2025, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Lucy Umana, Caregiver, and explained the purpose of the visit. Administrator, Arielle Lewis, met with LPA shortly after. The facility is licensed to serve (6) elderly adults ages 60 and above, of which (6) can be non-ambulatory. The facility has an approved hospice waiver for (5) residents. Currently there are (6) residents in the facility.

The facility is a single-story home located in a residential neighborhood, and it consists of the following: (6) resident bedrooms, (6) resident bathrooms, (1) staff room, (2) staff bathrooms, office, living room, dining room, and kitchen.

LPA Gonzalez and Arielle Lewis toured the physical plant. There were no bodies of water or obstructions on the premises. Exits/Walkways around the facility were free of debris and hazards. LPA inspected (3) resident bedrooms, and (3) resident bathrooms. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bathrooms were found to be operational and within Title 22 regulations. The water temperature properly measured between 105 F-120 F. LPA observed a comfortable temperature within the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored and inaccessible to residents in care. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguishers were charged and were operable. Smoke and carbon monoxide combo were tested and are working properly.

Continued on LIC 9099-C

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Elvira Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: AYRES RESIDENTIAL CARE HOME-CENTURY CITY
FACILITY NUMBER: 197602934
VISIT DATE: 09/17/2025
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LPA conducted a review of (6) resident service files, (3) staff personnel files and (3) Medication Administration Record (MAR). LPA observed all records were maintained in order. A stocked First Aid kit with manual was available. The most recent Fire/Emergency Drill was conducted on 06/10/2025. The facility's annual fees are current.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. There are sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted.

During this inspection, LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted, and a copy of the report was given to Arielle Lewis, Administrator.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Elvira Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
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