<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200906
Report Date: 03/10/2025
Date Signed: 03/10/2025 05:26:19 PM

Document Has Been Signed on 03/10/2025 05:26 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ALTIUS II ADULT RESIDENTIALFACILITY NUMBER:
198200906
ADMINISTRATOR/
DIRECTOR:		PEDRO PEREZFACILITY TYPE:
735
ADDRESS:3745 W. 157TH STREETTELEPHONE:
(310) 973-8249
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY: 6CENSUS: 4DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Maricela Pacheco, House ManagerTIME VISIT/
INSPECTION COMPLETED:
05:45 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 03/10/2025 at 2:15 pm, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Maricela Pacheco, House Manager and the purpose of today’s visit was explained. The facility is licensed to operate for (6) ambulatory who are developmentally disabled adults ages 18 through 59. Currently, the home has 4 clients. The clients are Westside Regional Center. None the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices.

The facility is a one (1) story home located in a residential neighborhood. The property consists of the following: 3 client bedrooms, 1 common bathroom, 1 half bathroom, a staff office, a living room, a kitchen, a dining room, attached garage, a laundry room with washer and dryer and an outdoor shaded area.

Between the hours of 2:50 pm - 4:25pm, LPA conducted a records review of (4) client records, (4) staff records, (4) Client Medication Administration Records, (4) clients Personal & Incidental Records and reviewed the facility disaster plan (conducted February 2025). All client & Staff records were complete. The facility disaster plan is current and in compliance with Title 22 at the time of visit.

Between the hours 2:25 pm - 2:39 LPA and Maricela Pacheco toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed , plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F (Kitchen 109.8F).

Report continues on LIC 809-C.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: ALTIUS II ADULT RESIDENTIAL
FACILITY NUMBER: 198200906
VISIT DATE: 03/10/2025
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
Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 6); LPA observed the following deficiencies:

  • On 03/10/2025, between the hours of 2:50pm - 4:04pm, LPA conducted a record review and observe no admission agreement on file for Resident #1.
  • On 03/10/2025, between the hours of 2:25pm - 2:39pm, upon interview House Manager states on March 7, 2025, the garage door is broke and needs to be repair.

Exit interview conducted with Maricela Pacheco (House Manager).
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 03/10/2025 05:26 PM - It Cannot Be Edited


Created By: Zina Brown On 03/10/2025 at 05:12 PM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ALTIUS II ADULT RESIDENTIAL
FACILITY NUMBER: 198200906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the house manager states the garage door broke on Friday, March 7th, 2025 and needs to be repaired. Therefore the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. Maricela Pacheco
POC Due Date: 03/31/2025
Plan of Correction
1
2
3
4
The licensee will submit proof of garage door being repaired by the POC date to the department via email at zina.brown@dss.ca.gov
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/10/2025 05:26 PM - It Cannot Be Edited


Created By: Zina Brown On 03/10/2025 at 05:12 PM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ALTIUS II ADULT RESIDENTIAL
FACILITY NUMBER: 198200906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)(1)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any. (1) Prior to admitting a developmentally disabled adult recommended by a Regional Center, the licensee of an ARF shall obtain from the Regional Center written certification which states that there was no objection to the placement by any persons specified in Welfare and Institutions Code Section 4803.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review an admission agreement was not on file at the time of annual inspection. Therefore, the licensee did not comply with the section cited above in for one out of four clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
1
2
3
4
The licensee will submit proof of admission agreement for Client #1 by the POC date to the department via email at zina.brown@dss.ca.gov
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4