198320541-3-21-2025-11-AS-RCLD-DEYMJM-20250321093923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320541
Report Date: 03/21/2025
Date Signed: 03/21/2025 09:39:35 AM

Document Has Been Signed on 03/21/2025 09:39 AM - 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:	BANFF FAMILY HOME		FACILITY NUMBER:	198320541
ADMINISTRATOR/ DIRECTOR:	ARBOLEDA,ANTONIO		FACILITY TYPE:	740
ADDRESS:	1311 W 218TH STREET		TELEPHONE:	(424) 558-8266
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 6		CENSUS: 0	DATE:	03/21/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:05 AM
MET WITH:	Administrator Antonio Arboleda		TIME VISIT/ INSPECTION COMPLETED:	09:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Regina Cloyd, conducted an announced visit to the facility for purpose of a prelicensing evaluation. An application was submitted to CCLD on 09/24/2024, for initial license for a Residential Care Facility for the Elderly to serve the Elderly for 60 years and older. The requested capacity is for six (6) non-ambulatory. The facility has an approved hospice waiver for four residents. Structure: Facility is a six (6) bedroom, two (2) bathroom, single story house. There is a large covered front porch and driveway that leads to the back porch with ramp. Bedrooms Residents: Bedrooms #1 - 6 are for non-ambulatory residents. Bedroom #2 has two beds, two chairs, two night stands/dressers, and two lamps in addition to overhead lighting. There are two dressers with three drawers and currently one closet. Bedrooms 1, 3-4, & 6 are currently setup as private rooms. Bedroom #5 is currently being used as a storage space. Bathrooms: Both bathrooms have a working toilet, wash basin, and step-in shower. Bathrooms will accommodate non-ambulatory residents in a wheel chair. Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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: BANFF FAMILY HOME	FACILITY NUMBER: 198320541
	VISIT DATE: 03/21/2025

NARRATIVE

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Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in room #5.

Emergency Phone Numbers, Exit Plan & Menu:
The facility has a working landline.
There are two fire extinguishers located in the kitchen and hallway.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer next to the sink. Food supply adequate stored in the cabinets and refrigerator and consists of the following: canned goods, fruit, meat, and vegetables. Dishwasher in kitchen properly installed and functioning.

Smoke Detectors & Carbon Monoxide Detector:
Electrical & connected.

Appliances:
Stove burners, oven, microwave, washer, and dryer working. There is one refrigerators in the kitchen. Each refrigerator has a measured temperature of at least 40 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat.

Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: BANFF FAMILY HOME	FACILITY NUMBER: 198320541
	VISIT DATE: 03/21/2025

NARRATIVE

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Toxins:
Locked/stored in.

Water Temperature:
Tested at 109 degrees.

Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in the kitchen cabinet, available for staff use but inaccessible to residents.

Reading Material, Games, Equipment & Materials:
The facility has board games and puzzles for the residents' use, commensurate with the plan of operation.

Pool/Jacuzzi & Pets:
None.

Fire clearance:
Fire Clearance with the following special conditions: rooms approved for non-ambulatory/bedridden,
approval of delayed egress or delayed egress with secured (locked) perimeter was approved on 02/11/2025.

Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: BANFF FAMILY HOME	FACILITY NUMBER: 198320541
	VISIT DATE: 03/21/2025

NARRATIVE

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Pre-licensing Checklist:
Completed by licensee and reviewed by LPA.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

Prelicensing:
An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC809 (FAS) - (06/04)

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