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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320118
Report Date: 10/06/2022
Date Signed: 10/06/2022 10:30:14 AM


Document Has Been Signed on 10/06/2022 10:30 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:PRIME VILLA CLOUDFACILITY NUMBER:
198320118
ADMINISTRATOR:ATENCIO, JOHN PAULFACILITY TYPE:
740
ADDRESS:1009 E MARCELLUS STTELEPHONE:
(562) 428-6084
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:6CENSUS: 5DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:ADMINISTRATOR JOHN ATENCIOTIME COMPLETED:
11:00 AM
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On 10/06/2022 at 09:00 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Prime Villa Cloud Facility. LPA Calderon was allowed entry into the facility by Administrator John Paul Atencio. Administrator Atencio asked infection control questions and took LPA Calderon temperature prior to entrance into the facility. The facility is licensed for SIX 59-year-old or older non-ambulatory adult clients. Currently, there are (5) non-ambulatory residents residing in the facility.

LPA Calderon explained to Administrator Atencio, 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: (3) resident service records, (3) resident medication records, (2) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 02/15/2022. The one story residential home consists of (4) resident bedrooms, (3) resident 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.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PRIME VILLA CLOUD
FACILITY NUMBER: 198320118
VISIT DATE: 10/06/2022
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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 resident’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 112 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 113 degrees Fahrenheit, bathroom #3 hot water temperature properly measured at 112 degrees Fahrenheit. Kitchen hot water temperature properly measured at 115 degrees Fahrenheit. Facility (3) Carbon Monoxide and (6) Smoke Detectors hard wired and connected were tested and are working properly. The facility (1) Fire Extinguisher were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. Two (2) resident files were reviewed and found to be complete. LPA Calderon reviewed (2) resident medications 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 Certification # 6054089740 expiration date of 12/04/2023 was valid at time of visit. The facility does NOT handle resident's money/cash resources. All the required documents are posted in the facility in a clearly visible area.

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 thirty-day supply of Personal Protective Equipment (PPE).

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PRIME VILLA CLOUD
FACILITY NUMBER: 198320118
VISIT DATE: 10/06/2022
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LPA Calderon advised the Staff 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.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did NOT observe any deficiencies therefore NO citations were issued to Administrator Atencio at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator John Paul Atencio.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC809 (FAS) - (06/04)
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