198201933-8-17-2024-11-AS-RCLD-D88UJT-20240817153803

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198201933
Report Date: 08/17/2024
Date Signed: 08/17/2024 03:38:30 PM

Document Has Been Signed on 08/17/2024 03:38 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:	PALOS VERDES VILLA LLC		FACILITY NUMBER:	198201933
ADMINISTRATOR:	BIENSTOCK, SETH		FACILITY TYPE:	740
ADDRESS:	29661 S WESTERN AVE		TELEPHONE:	(310) 547-9941
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	116	CENSUS: 83	DATE:	08/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Activities Director Cynthia Partida		TIME COMPLETED:	03:45 PM

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On 08/17/24 Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Activities Director Cynthia Partida. LPA explained the purpose of today’s visit. The facility is licensed to serve (116) non-ambulatory elderly adults ages 60 and above. Facility waiver approved for (10) hospice residents.

The facility is a three-story structure located in a residential neighborhood. It consists of (71) bedrooms, (77) full bathrooms, and (2) 1/2 bath, and shaded front yard. The first floor contains the following: medication room, nurses office, main lobby, laundry room, janitor closet, kitchen, dining room, activities lounge, TV room, beauty salon, and public telephone. The second floor contains the following: laundry room, linen closet, and game room/computer room. The third floor contains the following: linen’s closet, activity storage, and 3 miscellaneous storage closets.

The Activities Director accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the facility were clear of hazards.

Resident bedrooms (room #1, 16, 29, 29A, 30, 45, 58, 59, 66, 68) had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Continue to LIC 809-C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024

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: PALOS VERDES VILLA LLC	FACILITY NUMBER: 198201933
	VISIT DATE: 08/17/2024

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Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured at 111.6 (room 1), 113.7 (room 30), and 111.3 degree F (room 59). Resident bath towels and linen supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. First Aid kit was available. Fire extinguishers, last serviced February 20, 2024 was observed on each floor. Fire Inspection re-test was completed on 11/14/23.

Nine staff records were reviewed, 9 out of 9 staff records had required criminal record clearances or criminal record exemptions.

Nine resident records were reviewed and, 9 out of 9 resident records had medical assessments and pre-appraisal or reappraisals. Two medications were reviewed.

No deficiencies are being cited.

An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Licensed Vocational Nurse Valeria Garcia.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024

LIC809 (FAS) - (06/04)

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