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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609556
Report Date: 07/13/2022
Date Signed: 07/18/2022 08:01:24 AM

Document Has Been Signed on 07/18/2022 08:01 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AVALON MALIBUFACILITY NUMBER:
197609556
ADMINISTRATOR:HILLARY BERENSFACILITY TYPE:
772
ADDRESS:32420 PACIFIC COAST HWYTELEPHONE:
(310) 457-9111
CITY:MALIBUSTATE: CAZIP CODE:
90265
CAPACITY: 6CENSUS: 6DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Evan Nicol, Lashanea VallejoTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit inspection of the facility. LPA met with the Program Director, Evan Nicol and Nurse Manager, Lashanea Valleo, and explained the reason for the visit.

With the assistance of the Nurse Manager, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are hardwired and battery operated. There are carbon monoxide detectors that functions properly. There are fire extinguishers located in the kitchen. The charge date is 6/1/2022.

Kitchen: The kitchen appliances and fixtures were functional. Two chefs were observed preparing the client meals. LPA observed a sufficient amount of perishable and non-perishable food that were properly sealed and stored. Knives are stored in a locked drawer in the kitchen.

Bedrooms: There are six (6) bedrooms designated for client's use. All six bedrooms were were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are four (4) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 105-108 degrees Fahrenheit.

Common Areas: These included the living room, activity and dining room area. The common areas were properly furnished. Group room, Recreation room, and therapy room was observed to be free of any obstruction.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AVALON MALIBU
FACILITY NUMBER: 197609556
VISIT DATE: 07/13/2022
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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. Facility has a swimming pool, which was observed with a five foot fence around it's parameters and a combination lock in place at each entry to prevent clients from entering without supervision. Facility also has a beach path which is fenced and locked at all times. The outdoor area was free of hazards. The laundry area and detergents are located by the kitchen.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation. Centrally stored medications are maintained and locked at the nurses station.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC809 (FAS) - (06/04)
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