<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602227
Report Date: 09/19/2025
Date Signed: 09/19/2025 01:00:24 PM

Document Has Been Signed on 09/19/2025 01:00 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:ASAHI RESIDENTIAL CAREFACILITY NUMBER:
198602227
ADMINISTRATOR/
DIRECTOR:		KRISTINA FATIMA LACANILAOFACILITY TYPE:
740
ADDRESS:18527 DORMAN AVETELEPHONE:
(310) 327-1633
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6CENSUS: 5DATE:
09/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Kristina LacanilaoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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
On 09/19/25, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above. LPA met with Administrator, Kristina Lacanilao, and the purpose of today's visit was explained. LPA was granted entry into the facility. The facility is licensed to serve six (6) non-ambulatory residents aged 60 and over, two of which may be bedridden and has an approved hospice waiver for three (3). Currently there are 5 residents residing in the facility.
Physical Plant/Structure The facility is a single-story structure in a residential neighborhood. The facility consists of five (5) bedrooms, two (2) bathrooms, living room, dining room, kitchen, front yard, backyard, and garage. The front and backyard are landscaped and maintained. LPA observed a shaded patio in the backyard with table and chairs. All ramp railings are secured. All walkways outside were observed clean, clear, and free of debris, hazards, and obstructions. LPA did not observe any bodies of water on the property.
Bedrooms LPA inspected all bedrooms and found them to be clean and in good repair. LPA observed all bedrooms have the required furniture including a bed(s), dresser(s), chair(s), nightstand, and storage space for resident's personal belongings. All beds were observed with the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of linens in a cabinet in the hallway in good repair. All rooms were observed to have ample lighting.
Bathrooms LPA inspected the bathrooms in the facility. All bathrooms were found to meet Title 22 regulations. Showers had secured safety handrails, nonskid mats, and shower chairs available. LPA observed an ample supply of hygiene products stored in a cabinet under the bathroom counter and are inaccessible to residents. Cleaning products were observed secured in a locked cabinet under the bathroom sink. LPA observed an ample supply of towels stored in a cabinet in the hallway. The water temperature measured 111.2- degrees and 112.3- degrees Fahrenheit.
Kitchen LPA inspected the kitchen and found it to be clean and sanitary. All appliances were observed in
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2025
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 3
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)
Page: 2 of 3
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: ASAHI RESIDENTIAL CARE
FACILITY NUMBER: 198602227
VISIT DATE: 09/19/2025
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
26
27
28
29
30
31
32
good working repair and operable. LPA observed an ample supply of cutlery, dishware, and cookware in good repair. LPA observed a 3- day supply of perishable foods, and a 7- day supply of non-perishable foods properly labeled, dated, and packaged. Sharps and knives were observed in a secured locked drawer in the kitchen and are inaccessible to residents. Cleaning products were observed secured in a locked cabinet under the kitchen sink and are inaccessible to residents. The water temperature measured 107.3- degrees Fahrenheit.
Common Rooms During the time of visit the facility was appropriately furnished. The department inspected all common room and observed them to clean and in good repair. The living room has two couches and a recliner to accommodate all residents. There is a large table in the dining room to accommodate all residents. All walkways and hallways in the home were observed to be clean, clear, and free of hazards and obstructions. All rooms were observed to have ample lighting. The facility was maintained at a comfortable temperature.
Medications LPA observed Centrally Stored Medications in a locked cabinet in the hallway and are inaccessible to residents. All the medications were observed in their original packaging. LPA reviewed the medications and Medication Administration Record (MAR) for five (5) residents and found them to be consistent with properly documented records.
Files LPA reviewed five (5) resident files and found they contained required documents. LPA reviewed the Administrator and four (4) staff files and observed they contained the required training, certification, and documents. Staff training is conducted on Relias and each staff completes 20- hours of training annually. LPA informed the Administrator that Licensing fees are due on 10/21/2025. LPA received and reviewed a copy of the Liability Insurance through Acord valid till 07/01/2026.
Safety LPA observed a fully charged fire extinguisher mounted in the hallway last serviced on 08/22/2025. The last Fire Prevention Inspection was conducted by Torrance Fire Department on 11/3/2024. All smoke and carbon monoxide detectors were in compliance and operational. The last emergency drill was conducted on 08/11/25. LPA inspected the First Aid kit and found it contained the required items and a current manual. The facility has a working landline telephone.
Infection Control LPA observed a sanitizing station in the entry with hand sanitizer, face masks, a thermometer, and visitor log. LPA observed a 30- supply of Personal Protective Equipment (PPE). All Infection Control signs were observed posted.

According to the California Code of Regulations (Tittle 22, Division 6, Chapter 8) the department did not observe or cite any deficiencies.


An exit interview was conducted with Administrator Kristina Lacanilao, 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: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3