198320305-9-9-2022-11-AS-ASOO-CJ4R9C-20220909124919

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320305
Report Date: 09/09/2022
Date Signed: 09/09/2022 12:49:27 PM

Document Has Been Signed on 09/09/2022 12:49 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 CARE COTTAGE		FACILITY NUMBER:	198320305
ADMINISTRATOR:	MEDINA, MA. SALVACION		FACILITY TYPE:	740
ADDRESS:	1808 PENINSULA VERDE DR.		TELEPHONE:	(562) 356-7130
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 0	DATE:	09/09/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ma Salvacion Medina, Licensee		TIME COMPLETED:	01:00 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	Licensing Program Analysts (LPA) Ana Soto, (LPA) Wendy Gibbs conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation. LPA's met with Ma Salvacion Medina, Licensee. An application was submitted to Community Care Licensing Department (CCLD) on 04/25/22 for an initial license for an Residential Community Facility Elderly. They requested capacity is for (6) residents, (1) ambulatory, (4) non- ambulatory and (1) bedridden. Structure: Facility is a four (4) bedroom, two (2) full bathroom, it is a single story house with small front porch, mini ramp on the west, east, and south of the facility, covered back patio, laundry area in the 2 car attached garage. The facility is a beige stucco with half brick structure with small backyard and central air and heat. Front yard landscape is in good condition. Covered back patio has table, chairs, and storage closet. Signal System: Egress system in facility. Bedroom Residents: Bedrooms 2 & 4 will be private bedrooms and bedroom 1 & 3 will be share bedrooms. All four bedrooms are designated resident bedrooms properly equipped with regulation guidelines of one/two beds, one/two chairs, one/two night stands, one/two lamps and overhead lighting. Presently, no bedrooms are occupied. Bedroom Staff: No bedrooms will be used for awake staff. Bathrooms: 2 full bathroom are located on the west side of the facility in between bedroom #3 and bedroom #2 they have a working toilet, wash basin, and a walk-in shower with folding bench and non-skid mats. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in hallway closets. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers and menu are posted and readily available for review in the office area next to living room. Facility has not set up their land line telephone. 3 Fire extinguisher, 1- 2A10B;C mounted in living room wall, 2 - 2A10B;C mounted on the wall in the kitchen, 3 - 2A10B;C mounted on the wall of the garage, they are tagged with current annual check.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALOS VERDES CARE COTTAGE	FACILITY NUMBER: 198320305
	VISIT DATE: 09/09/2022

NARRATIVE

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Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in locked storage drawers in the kitchen cabinet below the stove top. Adequate food supply is stored in kitchen, and consists of the following: 2 day perishables, and 7 week non-perishables. Dishwasher in kitchen is properly installed and functioning. Smoke Detectors: There are 7 individual smoke detectors, and 2 battery operated carbon monoxide detectors 1 located living room wall next to fire extinguisher and 2 located in hallway near front door, both are operational. Appliances: Stove burners, oven, microwave, and washer/dryer are in working condition. There is one refrigerator in the home and 2 extra refrigerators in the garage. The residence is equipped with central heat and air conditioning. Toxins: Cleaning supplies, and toxins are stored in two locations: locked cabinet in the kitchen and locked in the garage. Water Temperature: Water was tested in bathrooms and kitchen sink within 116.5 degrees Fahrenheit range. Medication, First-Aid Kit & Book: Designated area for centrally stored medication in a cabinet located in the dining room with lock. A first-aid kit has been inspected which has at least the following: thermometer, tweezers ,scissors, antiseptic, bandages, gauze and current first aid manual, which are stored with medication cabinet in the dining room, available for staff use but inaccessible to clients. Clients & Staff Files: Designated area for files will be located in the cabinet in the dining room with lock. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. . Fire Clearance: Fire clearance indicate delayed egress and any locked perimeter. 4 bedrooms have auditory alarms on exit doors and all other exit doors have them too. Component III: Conducted at the Pre-Licensing visit.

During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in a cabinet by the front door. LPA observed licensee wearing mask, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing will be completed for staff when facility has residents, and required postings throughout the facility. Visitor designated area, facility has internet & IPAD for residents to use. Emergency contacts updated and posted; PPE's are enough for 15 days.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALOS VERDES CARE COTTAGE	FACILITY NUMBER: 198320305
	VISIT DATE: 09/09/2022

NARRATIVE

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The following items must be corrected and proof of correction shall be submitted to the CCLD office to the attention of LPA Soto, by 09/16/2022. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. Install Line land at facility.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA 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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC809 (FAS) - (06/04)

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