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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201933
Report Date: 08/10/2021
Date Signed: 08/10/2021 01:35:37 PM

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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PALOS VERDES VILLA LLCFACILITY NUMBER:
198201933
ADMINISTRATOR:BIENSTOCK, SETHFACILITY TYPE:
740
ADDRESS:29661 S WESTERN AVETELEPHONE:
(310) 547-9941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:116CENSUS: 88DATE:
08/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:ADMINISTRATOR LINDA CARDNEASTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA Calderon was met by Administrator Linda Cardneas and the purpose of today’s visit was explained. The facility is licensed to serve 116 elderly residents 65 and older.

There are currently 88 elder residents in care. There are 70 non-ambulatory and 18 ambulatory clients. The facility is a 3-story structure with 71 studios with a total 116 bedrooms and 6 common bathrooms, multimedia rooms, commercial kitchen, large dining room, and a large common patio and smoking patio.

LPA Calderon and Administrator Cardneas toured the physical plant. LPA Calderon checked bedrooms Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Common bathrooms were found to be within Title 22 regulations and were clean and operational. LPA Calderon observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were not accessible to clients.

During the visit, LPA Calderon observed the facility infection control practices. LPA Calderon observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA Calderon observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA Calderon observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Administrator Cardneas to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PALOS VERDES VILLA LLC
FACILITY NUMBER: 198201933
VISIT DATE: 08/10/2021
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During today’s visit there were no deficiencies under California code of regulation title 22, division 6, chapter 8.

Exit interview was held and a copy of the report was provided to Administrator Linda Cardneas.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC809 (FAS) - (06/04)
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