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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205095
Report Date: 08/07/2025
Date Signed: 08/07/2025 03:33:15 PM

Document Has Been Signed on 08/07/2025 03:33 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:SOUTH BAY RESIDENTIAL CARE HOMEFACILITY NUMBER:
198205095
ADMINISTRATOR/
DIRECTOR:		ELVIRA DAVIDFACILITY TYPE:
740
ADDRESS:2460 W. 229TH PLACETELEPHONE:
(310) 534-1953
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 4DATE:
08/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Antonia DionisioTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 08/07/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Administrator Antonia Dionisio. The facility is licensed for six residents and approved for two hospice residents. Bedroom #1 is approved for ambulatory only. Bedrooms 2, 3, and 4 are approved for non-ambulatory residents. Annual Fees are current.

The facility is a single-story home located in a residential neighborhood. There are four (4) bedrooms, two (2) resident bathrooms, 1/2 bathroom, living room, dining room, kitchen, laundry area, and attached garage.

The Administrator and House Manager accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed.

Resident bedrooms had the required furniture, bed linens, and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Continue to LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2025
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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Document Has Been Signed on 08/07/2025 03:33 PM - It Cannot Be Edited


Created By: Regina Cloyd On 08/07/2025 at 02:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SOUTH BAY RESIDENTIAL CARE HOME
FACILITY NUMBER: 198205095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above for one resident which poses an immediate safety risk to persons in care. During facility tour, LPA observed Resident #4 in bedroom #5. The fire inspection report and facility sketch on file with Community Care Licensing does not reflect a fifth bedroom.
POC Due Date: 08/08/2025
Plan of Correction
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The Licensee will submit evidence of correction to regina.cloyd@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Regina Cloyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/07/2025 03:33 PM - It Cannot Be Edited


Created By: Regina Cloyd On 08/07/2025 at 02:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SOUTH BAY RESIDENTIAL CARE HOME
FACILITY NUMBER: 198205095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above for two out of four residents which poses a potential health risk to persons in care. LPA did not observe an annual assessment for or decline of statement for an assessment from Resident #1 and Resident #3.
POC Due Date: 08/25/2025
Plan of Correction
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The Administrator will provide plans of correction to regina.cloyd@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Regina Cloyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2025


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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SOUTH BAY RESIDENTIAL CARE HOME
FACILITY NUMBER: 198205095
VISIT DATE: 08/07/2025
NARRATIVE
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Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and the shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinets. The first aid kit was available. The administrator tested the carbon monoxide detector and smoke detectors in the house. Devices were functional.

Four staff records were reviewed, 4 out of 4 staff records had the required criminal record clearances or criminal record exemptions.

Four resident records and two residents’ medication were reviewed.

Deficiencies are being cited in accordance with the California Code of Regulations, Title 22, see LIC809D. During the facility tour, LPA observed Resident #4 (R4) in bedroom #5. The fire department inspection does not reference a bedroom #5 and the facility sketch on file with Community Care Licensing Division does not reflect a bedroom #5. Civil penalties will be issued, see LIC421IM.

During record review, LPA did not observe an annual assessment for Resident #1 (R1) and Resident #3 (R3).

An exit interview was conducted, Plans of Corrections developed, and technical assistance provided. A copy of this report and appeals was discussed and left with Administrator Antonia Dionisio.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC809 (FAS) - (06/04)
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