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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201933
Report Date: 10/29/2022
Date Signed: 11/03/2022 04:35:25 PM


Document Has Been Signed on 11/03/2022 04:35 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
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:
10/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Cindy Partida, Activities DirectorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by ???, Supervisor and the purpose of today’s visit was explained.

There are currently (88) residents in the facility. The facility is a three-story structure located in a residential neighborhood. It consists (71) bedrooms, (77) full bathrooms, (2) 1/2 bath, shaded front yard, 1st floor - Medication room, nurses office, main lobby, laundry room, janitor closet, kitchen, dining room, activities lounge, TV room, beauty salon, Public telephone. 2nd floor - Laundry room, linen closet, game room/computer room, supply room storage PPE's. 3rd floor - Linens closet, activity storage, 3 miscellaneous storage closets.

During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the storage closets on the 2nd floor. LPA observed staff wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, No mitigation plan posted and/or in folder, No-fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & computers for residents to use, resident’s temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days.

Technical Advisory (TA) issued.

1. No fit testing completed for staff.

2. No mitigation posted and/or in binder

An exit interview conducted with Cindy Partida, Supervisor and a hard copy of report provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2022
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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