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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602191
Report Date: 09/11/2024
Date Signed: 09/18/2024 12:45:02 PM

Document Has Been Signed on 09/18/2024 12:45 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:CASA DEL SOL II RESIDENCEFACILITY NUMBER:
198602191
ADMINISTRATOR/
DIRECTOR:
YCHEAL D. LEVINEFACILITY TYPE:
740
ADDRESS:11600 W WASHINGTON BLVDTELEPHONE:
(310) 390-9045
CITY:CULVER CITYSTATE: CAZIP CODE:
90066
CAPACITY: 6CENSUS: 5DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Vida ZelayaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met staff member LVN Vida Zelaya and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently five (5), residents in placement. The facility's annual fees are current.

Staff member Ms. Vida and LPA Bunker toured the facility. The facility is a two-story building located in a residential-commercial neighborhood with, a dining room, 3 bedrooms, 3 bathrooms, and an indoor/outdoor activity area. Bedrooms #1-3 are designated as the client's bedrooms.
The residents' bedrooms had the required furniture, bed linens, and closet/drawer space to accommodate them comfortably. Resident bathrooms were checked. The toilets and water faucets worked properly, the grab bars were secure, the shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries, and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Food and meals are prepared in the main kitchen located in the skilled nursing facility and are brought to the residents on carts. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and the fire extinguisher was fully charged. During the visit, LPA observed the facility's infection control practices. LPA observed a screening station with sanitizer at the facility entrance and additional sanitation supplies in the nursing office that were inaccessible to the residents. LPA observed a sign-in sheet and temperature log for visitors. LPA's temperature was checked during the visit. LPA observed staff wearing masks. Each resident has their own individual room for isolation and required postings are throughout the facility.
Due to time constraints, LPA was unable to complete the visit and will return back at a later date to complete the visit.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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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