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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320306
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:27:33 PM


Document Has Been Signed on 12/14/2023 02:27 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:MARCOSA'S VILLAFACILITY NUMBER:
198320306
ADMINISTRATOR:FIGUEROA, JUN FAUSTO D.FACILITY TYPE:
740
ADDRESS:1024 E. FREELAND STREETTELEPHONE:
(562) 428-0033
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:6CENSUS: 6DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Rosita MatuteTIME COMPLETED:
02:30 PM
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On 12/14/23, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Rose Matute and explained the purpose of today’s visit. LPA was granted entry to this facility. The facility is licensed to operate for six (6) non-ambulatory elderly residents ages 60 and over. The facility has a hospice waiver approved for six (6).

This facility is a single-story residence located in a residential neighborhood. The home consists of five (5) bedrooms, four (4) bathrooms, kitchen, living room, laundry area and a dining room. The home has a detached garage and an outside shaded sitting area.

LPA toured the physical plant with Administrator Rose Matute. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. The bathrooms were found to be within Title 22 regulation. Water temperature properly measured between 105F-120F. A comfortable temperature was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Two fire extinguishers were fully charged. Smoke detectors and carbon monoxide were operable. First aid kit was checked an in order with manual. Toxins and sharps were locked and inaccessible to clients. Outside grounds were toured and no bodies of water were observed. Shaded patio furniture was accessible. Exits and walkways around the home were free of debris and hazards. Facility has a working telephone landline. A review of Medication Administration Records and Fire Drill are maintained and in order. The last fire drill was conducted on 10/01/23.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira GonzalezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MARCOSA'S VILLA
FACILITY NUMBER: 198320306
VISIT DATE: 12/14/2023
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

No deficiencies were cited at the time of this visit.



An exit interview was conducted, and a copy of this report along with appeal rights was provided to Administrator Rose Matute.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira GonzalezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC809 (FAS) - (06/04)
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