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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320051
Report Date: 12/05/2024
Date Signed: 12/06/2024 08:37:55 AM

Document Has Been Signed on 12/06/2024 08:37 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:PEPPER TREE ASSISTED LIVINGFACILITY NUMBER:
198320051
ADMINISTRATOR/
DIRECTOR:		LUZVIMINDA BASA PARAISOFACILITY TYPE:
740
ADDRESS:2353 251ST STREETTELEPHONE:
(424) 250-9786
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 6CENSUS: 5DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Staff Hilma MatiasTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 12/05/2024 at 09:00 AM, Licensing Program Analyst LPA) Jose Calderon conducted an unannounced annual inspection visit at the Pepper Tree Assisted Living Facility. LPA Calderon was allowed entry into the facility by Staff Hilma Matias. Staff Hilma Matias asked infection control questions and took LPA Calderon temperature prior to entrance into the facility. Facility is to operate a Residential Care Facility for 6 Elderly residents 60 years or older. Currently, there are five (5) residents residing in the facility, 60 and older.

LPA Calderon explained to Staff Hilma Matias, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Five (5) client service records, five (5) client medication records (MAR), two (2) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 10/01/2024. The one-story residential home consists of five (5) client bedrooms, four (4) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage and kitchen area.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PEPPER TREE ASSISTED LIVING
FACILITY NUMBER: 198320051
VISIT DATE: 12/05/2024
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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 109 degrees Fahrenheit, bathroom #2 hot water temperature properly measured at 110 degrees Fahrenheit, Bathroom #3 hot water temperature properly measured at 110 degrees Fahrenheit, and bathroom #4 hot water temperature properly measured at 112 degrees Fahrenheit. Kitchen hot water temperature properly measured at 115 degrees Fahrenheit. Facility (1) Carbon Monoxide and (5) Smoke Detectors hard wired operated and connected were tested and are working properly. The facility one (1) Fire Extinguishers was checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. The facility has a working landline telephone. All toxins and knifes are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility 2 first aid kit is fully stocked with manuals was checked and in order. Outside grounds were toured and there is no water feature observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Five (5) client files were reviewed and found to be complete. LPA Calderon reviewed five (5) resident medications (MAR) and they were all found to be administered according to doctor's orders. Two (2) staff files were checked and have the required documents. LPA Calderon noted the Administrator Marhlyn Sapugay Certification # 6018525740 expiration date of 10/03/2024 was NOT valid at time of inspection. The facility does not handle client's money/cash resources and no surety bond is needed. Commercial General Liability Policy #PCI6834654801 policy period from 02/10/2024 to 02/10/2025 underwritten by Primary Care Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Valencia to email LPA Calderon a full copy of the commercial insurance policy including all endorsements no later than 12/20/2024. All the required documents are posted in the facility in a clearly visible area.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PEPPER TREE ASSISTED LIVING
FACILITY NUMBER: 198320051
VISIT DATE: 12/05/2024
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and clients, sanitizing stations (Located in common areas and restrooms). LPA observed staff and clients were NOT wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

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

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did observe deficiencies therefore citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Staff Hilma Matias.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
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