197608244-10-30-2024-11-AS-WGIS-DAJVW4-20241030164720

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608244
Report Date: 10/30/2024
Date Signed: 10/30/2024 04:47:32 PM

Document Has Been Signed on 10/30/2024 04:47 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/ DIRECTOR:	MARIVI PITTS		FACILITY TYPE:	740
ADDRESS:	17419 ELGAR AVENUE		TELEPHONE:	(310) 817-4298
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	10/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:29 PM
MET WITH:	Bienvenido Cadungog		TIME VISIT/ INSPECTION COMPLETED:	05:00 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 10/30/24, the department conducted an unannounced annual visit using the full CAREs tool. The department met with Administrator, Bien Cadungog, and the purpose of today's visit was explained. The facility is licensed to serve five (5) non-ambulatory residents aged 60 and over. The facility is approved for one (1) bedridden resident and has an approved hospice waiver for two (2) residents. Currently there are four (4) residents residing at the facility. 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, sitting room, kitchen, laundry room, staff room, detached garage, a front yard, and a shaded patio area in the backyard with table and chairs. The department 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 and in good repair. All gates are accessible and open easily from the inside of the yards for an easy exit. Bedrooms The department 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’s personal belongings, and ample lighting. All beds had the required linens including a

Eva M Alvarez	TELEPHONE: (323) 981-1755
Wendy Gibbs	TELEPHONE: (323) 981-1755
	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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 4

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: 10/30/2024

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

mattress pad, fitted sheets, blanket, comforter, and pillow. The department observed an additional supply of linens stored in the residents’ closets.
Bathrooms The department inspected both bathrooms and found them to be within Tittle 22 regulations. The department observed the bathrooms to be clean and operational. Both bathrooms have secured safety handrails, non-skid mats, and shower chairs available. The department observed an ample supply of towels and resident toiletries secured in a cabinet in the bathrooms. The water temperature measured 108.2-degrees and 107.6-degrees Fahrenheit.
Kitchen The department inspected the kitchen and found it to be clean and sanitary. The department observed an ample supply of cutleries, dishware, and cookware in good repair. All appliances were tested and observed in good working repair. The department observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods properly stored and labeled. The department observed all sharps secured in a locked drawer in the kitchen and are inaccessible to residents. All cleaning supplies were observed secured in the locked cabinet under the kitchen sink and are inaccessible to residents. The water temperature measured 110.3-degrees Fahrenheit.
Common Rooms The department inspected all common rooms and found them to be clean and in good repair. The facility was observed to be appropriately furnished during the time of visit. The living room and sitting room have two couches to accommodate all residents. The department observed magazines and activities available for residents. The dining room has a large table and chairs and space to

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: 10/30/2024

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

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 The department observed two fully charged fire extinguisher mounted in the facility that were last serviced on 07/25/24. The last Fire Prevention Inspection was on 05/24/24. Smoke detectors and Carbon Monoxide detectors are in compliance and operational. The last Emergency Drill was conducted on 10/01/24. All exits are clearly marked with an EXIT sign. The department inspected the First Aid kit and found it contained the required items and a manual. The department 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.
Files The department reviewed three (3) staff files and found they contained the required documents, certification, and training. The department observed the Administrator’s Certificate is valid till 03/11/2025. The department reviewed four (4) resident files and observed they had the required documents. During facility file review, the department observed licensing fees are current.
Medications The department observed centrally stored medications secured in a locked cabinet in the kitchen and are inaccessible to residents. All medications were observed in their original packaging. The department reviewed medications and medication administration record (MAR) for four (4) residents and found them to be consistent with properly documented records.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 10/30/2024

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

Infection Control The department observed the facility’s visitor sign-in procedures and temperature log. The department observed sanitizing stations throughout the facility. The department observed all required infection control sign posted throughout the facility. The department observed a 90-day supply of PPEs stored in the garage.

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

The department conducted an exit interview with Caregiver, Ja Feliciano, 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: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4