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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320443
Report Date: 03/10/2025
Date Signed: 03/10/2025 01:20:04 PM

Document Has Been Signed on 03/10/2025 01:20 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:AMALFI LIVING, INC.FACILITY NUMBER:
198320443
ADMINISTRATOR/
DIRECTOR:		LAYUG, TINYFACILITY TYPE:
740
ADDRESS:23518 EVALYN AVETELEPHONE:
(310) 525-8552
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 6CENSUS: 6DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Tina Cinco, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 03/10/2025 at 08:40 am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one year inspection. LPA met with Tina Cinco, Licensee and the purpose of the visit was discussed. Facility is licensed to age range 60 and over to serve six (6) non- ambulatory residents of which one (1) may be bedridden in Room 4 with a waiver/granted for hospice care for six(6) on 01.11.2024 by the department. Three (3) residents are diagnosed with dementia, two (2) residents are receiving home health, and two (2) hospice care services. The facility does not handle any of the residents’ money. The facility annual fees have been paid in full. The liability insurance is with James River Insurance (policy # 0091573-5) with each occurrence is $1,000,000 and general aggregate is $3,000,000 which is valid from 05/07/2024 - 05/07/2025.

The home is a single story home consisting of: (4) resident bedrooms, (2) full bathroom, a living room, kitchen with dining area, a garage (attached with a laundry area, an additional refrigerator and pantry items), a backyard with a shed, an outdoor shaded patio area and additional sitting area outside.

Between the hours of 9:28am - 9:45am, LPA toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured at 120.4 (in bathroom #1), 118.0F (in bathroom #2) and 120.6 (in the kitchen). Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

LPA conducted a records review of (6) client records, (6) staff records, (6)Medication Administrator Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was conducted on 02/01/2025 and in compliance with Title 22 at the time of visit.

Report continues on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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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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: AMALFI LIVING, INC.
FACILITY NUMBER: 198320443
VISIT DATE: 03/10/2025
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Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); LPA observed the following deficiencies:

On 03/10/2025, between the hours of 09:28 am - 09:45 am while LPA was conducting a tour of the physical plant, and observed Resident #3 located in Room #3. Upon, LPA reviewing the facility records (facility sketch, fire safety inspection request), between the hours of 10:10 am - 11:24am, LPA observe the facility license states bedridden resident must be located in Room #4.

An exit interview was conducted Tina Cinco (Licensee), and a copy of Report and Appeal Rights provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/10/2025 01:20 PM - It Cannot Be Edited


Created By: Zina Brown On 03/10/2025 at 12:14 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: AMALFI LIVING, INC.
FACILITY NUMBER: 198320443

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
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: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, resident #3 is located in room #3 which is not the assigned bedridden room according to the facility sketch (Room 4) is for bedridden room. Therefore the licensee did not comply with the section cited above in one out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
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The licensee will have a primary physician, re-evaulate the resident and update the LIC 603 RCFE Physician Report for Resident #3 ambulatory status, which will state if resident #3 is ambulatory or non-ambulatory.
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.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
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