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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603193
Report Date: 03/11/2025
Date Signed: 03/11/2025 11:50:40 AM

Document Has Been Signed on 03/11/2025 11:50 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CERRITOS ASSISTED LIVINGFACILITY NUMBER:
198603193
ADMINISTRATOR/
DIRECTOR:		SANTA ANA, OSVALDOFACILITY TYPE:
740
ADDRESS:18511 KAMSTRA AVENUETELEPHONE:
(562) 637-3392
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: DATE:
03/11/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Osvaldo Santa Ana, Licensee/Administrator TIME VISIT/
INSPECTION COMPLETED:
11:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Noemi Galarza made unannounced healthy and safety case management visit to check on new relocated resident whom was relocated on 3/7/2025 from Alain Crest # 197607462. LPA met with Abigail Despi caregiver staff and explained the purpose of the visit. Assistant Administrator Runette Catibog arrived shortly after. Administrator Osvaldo Santa Ana arrived later. A physical plant tour of the facility was completed.

The following observations were made:
  • Resident (R1) is in a shared room. The room has required furniture.
  • Medication Administration Records (MARs), medications, resident file documents were reviewed.
  • Sufficient staff was observed. However, caregiver staff (S1) is not associated to the facility. A civil penalty is being assessed. Assistant Administrator associated S1 during the visit.
  • LIC 500 Personnel Report needs to be updated.
  • The facility has sufficient 2-day perishable and 7-day non perishable food supplies. T
  • The last fire drill was conducted on 3/7/2025.
  • Two (2) half rails were observed in R2's bed. However, the resident is not enrolled in hospice services.



Exit interview was conducted with Administrator Osvaldo Santa Ana and a copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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Document Has Been Signed on 03/11/2025 11:50 AM - It Cannot Be Edited


Created By: Noemi Galarza On 03/11/2025 at 11:26 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CERRITOS ASSISTED LIVING
FACILITY NUMBER: 198603193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/12/2025
Section Cited
CCR
87608(a)(5)(B)

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Postural Supports. Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
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Staff removed one half rail from R2's bed during the visit.

Submit proof of staff training by tomorrow.

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Based on observation, resident R2 has two (2) half rails on their hospital bed, converting it to full rails. R2 is not enrolled in hospice care services, which poses an immediate health, safety or personal rights risk to resident in care.
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Type A
03/12/2025
Section Cited
CCR87355(e)(3)

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Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced by:
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Licensee shall ensure that all persons prior to working at the facility are associated through Guardian system. A civil penalty was assessed.

Assistant Administrator associated S1 via Guardian during the visit. ***Cleared.
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This requirement was not met evidenced by:
Based on file review caregiver staff (S1) is cleared, but not associated to the facility; which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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