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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603026
Report Date: 09/25/2024
Date Signed: 09/25/2024 03:30:11 PM

Document Has Been Signed on 09/25/2024 03:30 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:SUMMER BREEZE MANORFACILITY NUMBER:
198603026
ADMINISTRATOR/
DIRECTOR:		BAUTISTA, TERESITAFACILITY TYPE:
740
ADDRESS:1558 W 216TH STTELEPHONE:
(310) 418-7938
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 3DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Supervisor Joel MoralesTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 09/25/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an required – annual inspection and met with Supervisor Joel Morales.

Facility is licensed to serve six (6) non-ambulatory residents and has an approved hospice waiver for six (6) residents. The facility has two bathrooms, four bedrooms (two rooms are shared), staff room, kitchen, living room, dining rooms, two outdoor patios, and laundry room. The facility is clean, sanitary, and in good repair.



Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and 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.
Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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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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: SUMMER BREEZE MANOR
FACILITY NUMBER: 198603026
VISIT DATE: 09/25/2024
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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced August 8, 2024, was observed in the kitchen and dining room area. The Supervisor tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

Five staff records were reviewed, five out of five staff records had required criminal record clearances or criminal record exemptions.

Three resident records were reviewed and, three out of three resident records had medical assessments and pre-appraisal. Two residents’ medication was reviewed.

No deficiencies are being cited.

An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Supervisor Joel Morales.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
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