198320277-8-9-2023-11-AS-FSHY-CUJU9M-20230809152323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320277
Report Date: 08/09/2023
Date Signed: 08/09/2023 03:23:28 PM

Document Has Been Signed on 08/09/2023 03:23 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	LEGACY VILLA SENIOR CARE		FACILITY NUMBER:	198320277
ADMINISTRATOR:	CLARKE, STEPHEN		FACILITY TYPE:	740
ADDRESS:	21012 DOBLE AVENUE		TELEPHONE:	(310) 418-7938
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90502
CAPACITY: 6		CENSUS: 4	DATE:	08/09/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	01:02 PM
MET WITH:	Stephen Clarke		TIME COMPLETED:	03:45 PM

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On 8/9/23, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit with a primary focus on Infection Control measures using the CARE Inspection Tools. LPA met with Joel Morales, and the purpose of this visit was explained. The facility is licensed for six (6) individuals, of which two (2) ambulatory, four (4) non-ambulatory, and zero (0) bedridden. Today’s census is 4.

The home is a five (5) bedroom, three (3) bathroom, one-story home with a two (2) car garage situated in a residential neighborhood. The home includes a living, dining, kitchen, and laundry area.

LPA walked through all five (5) rooms. All bedrooms contained a bed, dresser, nightstand, chair, ample lighting and closet space. Beds linens and comforters were in good condition, adequate lighting provided, storage for client personal belongings was observed.

LPA walked through the kitchen and all appliances were in good working order. Knives were locked and stored in a drawer in the kitchen and inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured at 112.2 degrees Fahrenheit.

All bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly. The walk-in shower was free of mildew and mold and had shower chairs available. LPA walked through the laundry room, all cleaning products were locked in a cabinet and inaccessible to residents.

LPA walked through all common areas. In the living room, family room, dining room and there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, family room and living room have working smoke detectors.

con'd on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LEGACY VILLA SENIOR CARE	FACILITY NUMBER: 198320277
	VISIT DATE: 08/09/2023

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Sufficient paper, cleaning, and disinfecting supplies were observed. The garage is used as storage. LPA observed an ample supply of resident care items. There was additional food and supplies stored.

LPA walked the outside of the facility. In the back yard there is a table, chairs and umbrella for residents and visitors use. All walkways were clear of debris, obstructions and hazards. LPA did not observe any bodies of water.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report provided to Supervisor, Joel Morales.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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