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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320013
Report Date: 06/24/2025
Date Signed: 06/24/2025 02:50:17 PM

Document Has Been Signed on 06/24/2025 02:50 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:SENIOR MANOR CARE IIIFACILITY NUMBER:
198320013
ADMINISTRATOR/
DIRECTOR:		STEPHEN GRADNEYFACILITY TYPE:
740
ADDRESS:2423 SANTA FE AVETELEPHONE:
(310) 212-0883
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 5DATE:
06/24/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Caregiver Rita MelindawatiTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 06/24/25, Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced case management – deficiency and met with Staff and explained the purpose of this visit. The purpose of this visit is to issue a deficiency observed on 06/06/25 and during today’s visit. On 06/06/25, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent unannounced annual continuation and met with Staff. The facility is licensed to serve six (6) non-ambulatory residents, of which one may be bedridden. The facility has a hospice waiver approved for six residents. Bedrooms #1, #2, and #4 are approved for non-ambulatory or bedridden residents.

Regional Office record review of the Fire Inspection Request by the Torrance Fire Department on 04/16/2019 indicates that only bedrooms #1, #2, and #4 are approved for non-ambulatory/bedridden residents. On 06/06/25, record review of register of residents revealed two non-ambulatory residents (R3 and R5) in rooms #3 and #5. Record review of medical assessment revealed R3 and R5 as non-ambulatory.

Deficiencies are being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809D. An immediate civil penalty of $500 is issued.

An exit interview was conducted, plans of correction developed, and a copy of this report and appeal rights was discussed and left with Caregiver Rita Melindawati.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2025
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 06/24/2025 02:50 PM - It Cannot Be Edited


Created By: Regina Cloyd On 06/24/2025 at 02:39 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: SENIOR MANOR CARE III
FACILITY NUMBER: 198320013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2025
Section Cited
CCR
87202(a)

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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department,... Prior to accepting or retaining... persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance...
This requirement was not met as evidence by
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The Licensee agree to obtain a fire safety inspection to increase the number of rooms approved for non-ambulatory residents. The Licensee will create a plan, indicating specific steps to be taken by staff, based on the Fire Marshal’s guidance to ensure the residents’ safety.
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Based on record review, bedrooms #1, #2, and #4 are approved for non-ambulatory or bedridden residents. Licensee accepted R3 and R5 (non-ambulatory) into ambulatory rooms (#3 and #5). This poses an immediate 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: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2025


LIC809 (FAS) - (06/04)
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