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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205095
Report Date: 08/19/2025
Date Signed: 08/19/2025 04:15:05 PM

Document Has Been Signed on 08/19/2025 04:15 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: DATE:
08/19/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:41 PM
MET WITH:Antonia DionisioTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 08/19/2025, an Office Meeting was held at the El Segundo Adult and Senior Care Program Regional Office. Participants in this meeting included Licensing Program Manager (LPM) Ulysses Coronel, Licensing Program Analyst (LPA) Regina Cloyd and Administrator Antonia Dionisio.

The purpose of this conference is to discuss the concerns observed by the Department during the annual facility evaluation inspection conducted on 08/07/25.

During the meeting, the Administrator indicated that she did not have knowledge that the outdoor patio was not permitted to be constructed for another use (bedroom #5) without a building permit, fire inspection, and Community Care Licensing Division approval.

A citation is issued according to California Code of Regulations Title 22, Division 6, Chapter 8, Article 07. Personnel 87405(d)(2) Administrator – Qualifications and Duties; see LIC809-D.

Continue to LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2025
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: SOUTH BAY RESIDENTIAL CARE HOME
FACILITY NUMBER: 198205095
VISIT DATE: 08/19/2025
NARRATIVE
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The Administrator stated the following plans in order to bring the facility into compliance:

- The Property Owner will restore bedroom #5 back to an outdoor patio;

- The Administrator will ensure the safety of the residents during demolition.

An exit interview was conducted, plans of correction developed, and a copy of this report with the appeal rights was provided to the Administrator Antonia Dionisio.

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

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/19/2025 04:15 PM - It Cannot Be Edited


Created By: Regina Cloyd On 08/19/2025 at 03:44 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: 08/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2025
Section Cited
CCR
87405(d)(2)

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(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
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The Administrator will review the regulations on 87305 Alterations to Existing Building or New Facilities and 87202 Fire Clearance and send evidence of correction to regina.cloyd@dss.ca.gov.
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This requirement was not met as evidence by: the Administrator allowed residents to use a bedroom without obtaining a fire clearancel. This poses a potential safety risk to residents in care.
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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: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
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