198320118-10-2-2020-11-AS-KWIS-BTZVMK-20201002163339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320118
Report Date: 10/02/2020
Date Signed: 10/02/2020 04:34:45 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:	PRIME VILLA CLOUD		FACILITY NUMBER:	198320118
ADMINISTRATOR:	ATENCIO, JOHN PAUL		FACILITY TYPE:	740
ADDRESS:	1009 E MARCELLUS ST		TELEPHONE:	(562) 428-6084
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	6	CENSUS: 5	DATE:	10/02/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	John Atencio, Administrator		TIME COMPLETED:	12:00 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 10/02/20 at 9:41 am Licensing Program Analyst (LPA) Kourtney Williams conducted a pre licensing visit at facility. In accordance with Governor's Proclamation has set forth, LPA is unable to make a physical inspection due to COVID-19. Today’s visit was conducted telephonically with John Atencio Administrator. LPA explained the purpose of the visit and started the virtual meeting via zoom. An application was submitted to CCLD on 6/15/2020. In the initial license application for a Residential Care Facility for the Elderly, ages ranging from 60 years and above.The applicant requested for a capacity of 6 individuals, of which 0 are ambulatory, 4 are non-ambulatory and 2 are bedridden. LPA was greeted and accompanied by applicant John Atencio during the inspection. Structure: Facility is a four (4) bedroom, two (2) bathroom, one- story home with a two (2) car detached garage situated in a residential neighborhood. The facility is a cream-colored house with a u -shaped driveway and the structure includes: living, dining, kitchen and activity areas. The living room area has no fireplace. The living area included sectional sofa and a coffee table. Also has two (2) chairs, a loves seat and a piano. The kitchen has a refrigerator and stove. The exterior is rear fenced throughout. The passageways, walkways and steps are free from obstructions. The patio area has outside tables each table has four (4) chairs . Shaded area throughout the backyard. There is another small table with two (2) chairs. Rooms: The facility had four (4) rooms for client. The facility had one (1) offices . All rooms had closets for ample storage. Bedrooms Staff: No staff bedrooms.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Kourtney Williams	TELEPHONE: (510) 301-5810
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020

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: PRIME VILLA CLOUD	FACILITY NUMBER: 198320118
	VISIT DATE: 10/02/2020

NARRATIVE

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Bathrooms:
The facility had two (2) bathrooms. All bathrooms have a working toilet and wash bin. Bathroom # 2 is shared.

Linens & Hygiene Supplies:
Adequate supply of towels in the laundry room . For clients to use once.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. exit plan are posted and readily available for review near the entrance. There is one (1) in fire extinguisher fully charged in the kitchen near the sink. One in the kitchen. A telephone line is available in the facility near the kitchen.

Food Service:
Dishes, cups and flatware are stored in the kitchen cabinets, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet near the refrigerator. The kitchen counters also had small appliances.
Smoke Detectors:
Smoke and carbon monoxide detectors are interconnected and working throughout the facility. Administrator tested all the smoke detectors in the resident’s rooms and in the hallway.

Appliances:
Stove , oven, microwave, washer, and dryer are working. Dishwasher is in the kitchen properly installed and functioning. The kitchen counters also had small appliances which includes a countertop , toaster, water heater and a blender. There is one (1) refrigerator inside the home. The refrigerator has a measured temperature of at least 40 degrees Fahrenheit for appropriate food storage. Freezer is at (0) degrees Fahrenheit.

Toxins:
All toxins are locked/stored in cabinet located in a locked panty .The sharps were locked in the kitchen.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Kourtney Williams	TELEPHONE: (510) 301-5810
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020

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: PRIME VILLA CLOUD	FACILITY NUMBER: 198320118
	VISIT DATE: 10/02/2020

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Water Temperature:
Temperature is at 110.8 F in the kitchen sink. Bathroom #1 measured at 110.8. F. Bathroom #2 is measured at 109. F.
Medications, First-Aid Kit & Book:
A first aid kit stored First Aid Kit: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual. Client's medications will be stored in the back office locked and inaccessible to clients.

Clients & Staff Files:

Applicant is not handling cash resources of clients .Records of staff and clients will be stored in the foyer in the front of the house locked in a cabinet.

Reading Material, Games, Equipment & Materials:
The facility has a piano and a library . There is also equipment for the resident to use as activities to commensurate with the plan of operation.

Pool/Jacuzzi & Pets:

There are no pets, jacuzzi or pool in the fenced area.

Fire clearance:

Fire Clearance 07/14/2020 with approval for a capacity for two (2) bedridden, four (4) non-ambulatory and zero (0) for ambulatory.

Component III:
LPA Kourtney Williams conducted at the Pre-Licensing visit; information provided about how to operate the facility within substantial compliance.

LPA observed no corrections during this pre-licensing inspection.

An exit interview was conducted, and a copy of this report has been furnished to the applicant, John Atencio LPA/Kourtney Williams will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Kourtney Williams	TELEPHONE: (510) 301-5810
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020

LIC809 (FAS) - (06/04)

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