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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320628
Report Date: 10/31/2025
Date Signed: 10/31/2025 12:24:27 PM

Document Has Been Signed on 10/31/2025 12:24 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:KIZUNA HOMECARE LLCFACILITY NUMBER:
198320628
ADMINISTRATOR/
DIRECTOR:		TOJO, ANA AILILFACILITY TYPE:
740
ADDRESS:18349 AMIE AVETELEPHONE:
(310) 214-2659
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6CENSUS: 6DATE:
10/31/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:41 AM
MET WITH:Ana TojoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 10/31/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a scheduled Pre-Licensing to the facility listed above. LPA met with Administrator, Ana Tojo, and the purpose of today’s visit was explained. LPA was granted entry into the facility.
An application was received by CCLD on 07/10/2025, for a Change of Ownership. The facility is a Residential Care Facility for the Elderly that serves residents aged 60 and over. The facility has an approved fire clearance for six (6) non-ambulatory residents, two of which may be bedridden in bedrooms 1 and 3, and an approved Hospice Waiver for 3.
Physical Plant/Structure The facility is a single-story structure in a residential neighborhood. It consists of four (4) resident bedrooms, two (2) bathrooms, kitchen, dining area, living area, attached garage, and outside activity area. The outside activity area has a table, with chairs and umbrellas. All walkways around the facility were observed clean, clear, and free of debris, obstruction, and hazards. LPA observed a pool in the back yard that has a fence around it and is inaccessible to residents. All windows, screens, and blinds were observed to be in good repair. LPA observed a screened fireplace that is inaccessible to residents.
Bedrooms LPA inspected all residents’ bedrooms. LPA observed the residents’ rooms were clean and in good repair. LPA observed the rooms have the required furniture including a bed, dresser, nightstand, chair, and storage space for resident’s personal belongings. LPA observed the beds have the required linens including a mattress cover, fitted sheet, blankets, comforter, and pillows. Bedrooms were observed with ample lighting. LPA observed an ample supply of linens in a closet in the hallway.
Bathroom LPA inspected all bathrooms and observed them to be operable and within Title 22 regulations. LPA observed all showers were clean and free of mildew and mold. All safety handrails are securely fastened. LPA observed nonskid mats and shower chairs available in the showers. LPA observed an ample supply of toiletries, towels, and wash clothes for residents. The water temperature in the bathrooms
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2025
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
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: KIZUNA HOMECARE LLC
FACILITY NUMBER: 198320628
VISIT DATE: 10/31/2025
NARRATIVE
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measured 115.8-degrees and 116.5-degrees Fahrenheit.
Kitchen LPA inspected the kitchen and found it to be clean and sanitary. All appliances were observed operational and in good repair. LPA observed an ample supply of cookware, dishware, and cutlery. LPA observed a 2-day supply of perishable foods, and 7-day supply of nonperishable foods properly labeled and stored. The water temperature measured 108.4-degrees Fahrenheit. LPA observed knives and sharps secured in a locked drawer. All cleaning supplies were observed secured in the locked cabinet under the sink.
Common Areas During the facility inspection, LPA observed in the living area there is a couch and three recliners to accommodate residents. LPA observed an ample supply of games, activities, crafts and reading material available. The dining room has a large table with chairs to accommodate residents. LPA observed the facility to be appropriately furnished at the time of visit. All rooms were observed clean and in good repair. LPA observed all rooms and hallways have ample lighting. The hallways have night lights. All walkways and hallways in the facility were observed clean, clear, and free of obstructions and hazards. The facility was maintained at a comfortable temperature.
Files LPA observed resident files and staff files secured in a locked file cabinet in the staff work area and are inaccessible to residents. LPA observed the Administrator has a valid Administrator Certificate, number 7016645740, active till 07/20/2026. LPA received and reviewed a copy of the facility’s Emergency and Disaster Plan For Residential Care Facilities for the Elderly (LIC610E). LPA observed a copy of the LIC610E posted in the facility in a hallway. LPA received and reviewed a copy of the facility’s Infection Control Plan. LPA observed a copy of the facility’s Infection Control Plan posted in the hallway. LPA observed all required signs and information posted inside the facility. LPA received and reviewed the liability insurance through Acord that is valid till 12/02/2025.
Medications LPA observed Centrally Stored Medication secured in a locked cabinet in the staff work area and are inaccessible to residents. LPA observed and tested the lock on the medication cabinet. Medications are documented on a Medication Administration Record (MAR).
Safety LPA observed two (2) fully charged fire extinguishers purchased in December 2024. LPA observed and tested all smoke detectors and carbon monoxide detectors and found them to be operable. All doors, exiting the facility, have an alarm that chimes when it is opened. The facility has a working landline telephone. LPA observed a First Aid kit with the required items and a current manual secured in the medication cabinet. LPA observed a supply of emergency food and water. LPA observed a supply of emergency lighting and batteries. There are no firearms or ammunition on the premises.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: KIZUNA HOMECARE LLC
FACILITY NUMBER: 198320628
VISIT DATE: 10/31/2025
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Infection Control Upon entry, LPA observed a sanitizing station that consisted of a Visitor Sing in log, hand sanitizer, thermometer, and masks available. LPA observed required Infection Control signs posted in the facility. LPA observed an ample supply of cleaning products secured in locked cabinets.

Administrator and LPA reviewed and discussed Component III.

LPA did not observe any advisory deficiencies or violations.

An exit interview was conducted with Administrator, Ana Tojo, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC809 (FAS) - (06/04)
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