197608244-10-19-2023-11-AS-WGIS-CWRRSJ-20231019131649

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608244
Report Date: 10/19/2023
Date Signed: 10/19/2023 01:17:01 PM

Document Has Been Signed on 10/19/2023 01:17 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:	ROYAL PALMS VILLA		FACILITY NUMBER:	197608244
ADMINISTRATOR:	MARIVI PITTS		FACILITY TYPE:	740
ADDRESS:	17419 ELGAR AVENUE		TELEPHONE:	(310) 817-4298
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 3	DATE:	10/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Marivi Pitts		TIME COMPLETED:	01:30 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 10/19/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit using the full CAREs tool. LPA met with Administrator, Marivi Pitts, and the purpose of today's visit was explained. Currently there are three residents residing at the facility, and one is currently receiving Hospice Care. Structure/Physical Plant The facility is a single-story home in a residential neighborhood. It consists of 6 bedrooms, 2 bathrooms, living room, dining room, den, kitchen, laundry room, detached garage, a front yard, and a shaded patio area in the backyard with table and chairs. LPA did not observe any bodies of water on the premises. All outside walkways were observed to be clean, clear, and free of hazards, debris, and obstructions. All railings for ramps and stairs were secured. All gates are accessible and open easily from the inside of the yards for an easy exit. Bedrooms LPA inspected all bedrooms and found them to be clean and in good repair. All bedrooms contained the required furniture, including a bed, dresser, nightstand with lamp, chair, storage space for resident personal belongings, and ample lighting. All beds had the required linens including a mattress pad, fitted sheets, blanket, comforter, and pillow. LPA observed an additional supply of linens stored in the residents’ closets. Bathrooms LPA inspected both bathrooms and found to be within Tittle 22 regulations. LPA observed the bathroom to be clean and operational. Both bathrooms have secured safety handrails, non-skid mats, and shower chair available. LPA observed an ample supply of towels and resident toiletries secured in a cabinet in the bathrooms. The water temperature measured 108.5-degrees Fahrenheit. Kitchen LPA inspected the kitchen and found it to be clean and sanitary. LPA observed an ample supply of cutleries, pots and pans in good repair. All appliances were tested and observed in good working order. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods. LPA observed all sharps secured in a locked drawer in the kitchen. All cleaning supplies were observed secured in the locked cupboard under the kitchen sink. The water temperature measured 106.2-degrees Fahrenheit. Continued on LIC-809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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: ROYAL PALMS VILLA	FACILITY NUMBER: 197608244
	VISIT DATE: 10/19/2023

NARRATIVE

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Common Rooms LPA inspected all common rooms and found them to be clean and in good repair. The living room and family room have two couches to accommodate all residents. LPA observed magazines and activities available for residents. The dining room has a large table and chairs and space to accommodate all residents. All walkways and hallways inside the facility were observed clean, clear, and free of obstructions and hazards. All rooms and hallways have ample lighting.
Safety LPA observed two fully charged fire extinguisher mounted in the facility that were last serviced on 07/21/23. The last Fire Prevention Inspection was on 09/15/23. Smoke detectors and Carbon Monoxide detectors are in compliance and operational. The last Emergency Drill was conducted on 09/26/23. All exits are clearly marked. LPA inspected the First Aid kit and found it contained the required items and a manual. LPA observed all required postings, posted throughout the facility. The facility has a working landline telephone. There are no firearms or ammunition stored on the premises.
Medications LPA observed centrally stored medications secured in a locked cabinet in the kitchen and are inaccessible to residents. LPA reviewed medications for two residents and compared them to the medication distribution chart and found them to be consistent.
Infection Control LPA observed the facilities visitor sign-in procedures and temperature log. LPA observed sanitizing stations throughout the facility. LPA observed all required infection control sign posted throughout the facility. LPA observed a 90-day supply of PPEs stored in the garage. LPA observed visitors wearing masks in the facility.
Files/Interviews LPA reviewed 2 resident files and found they contained the required documents. LPA interviewed 1 resident who was happy with their care received at the facility and 2 residents were unavailable for interviews during the time of visit. LPA reviewed 4 staff files and found they contained the required documents, certification, and training. LPA conducted interviews with 3 staff, and all staff were able to answer questions regarding resident care, resident rights, policy and procedure.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe or cite any deficiencies during today's visit.

LPA conducted an exit interview with Administrator, Marivi Pitts, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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