198320327-3-10-2023-11-AS-LVIS-CPRSR5-20230309130547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320327
Report Date: 03/09/2023
Date Signed: 03/10/2023 07:55:18 AM

Document Has Been Signed on 03/10/2023 07:55 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:	LUXURY ASSISTED LIVING LLC		FACILITY NUMBER:	198320327
ADMINISTRATOR:	MALYSHEV, DMITRY		FACILITY TYPE:	740
ADDRESS:	22901 MEYLER AVE		TELEPHONE:	(415) 225-8181
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90502
CAPACITY:	6	CENSUS:	DATE:	03/09/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Dmitry Alyshev		TIME COMPLETED:	01:20 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 March 9, 2023 Licensing Program Analyst (LPA) Lizeth Villegas conducted an announced visit to the facility for purpose of a prelicensing evaluation as an application was submitted to CCLD for Initial license. The residential care facility is to accommodate residents ages 60 and over and is approved for six (6) non-ambulatory, one (1) of which can be bedridden in room two (2) only and has a hospice waiver for three (3). At the time of the visit administrator reported that at this time he will not be excepting residents with dementia, Administrator was advised to inform licensing department if this changes. Facility is a single story 4-bedroom, 2 common bathroom, 1 common area, a kitchen, a 2 car de-attached garage used for storage, laundry area, linen closet and a large outdoor shaded patio area. The client bedrooms are spacious and will easily accommodate the client's furnishings. All passageways, walkways, driveways and patios are free from obstructions. All bathrooms have a working toilet, wash basin and a shower that will accommodate resident’s wheelchair. All water temperatures measured between 110 to 118 F. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Additional supplies are stored in the linen closet. Emergency plan, emergency exit plans and emergency phone numbers are all posted & readily available for review in entryway. There are two fire Extinguisher, one located in kitchen and a second extinguisher is in linen closet. Facility has a landline, one phone locating in the kitchen and one phone located at the entryway. Dishes, cups and plates ware are stored in the kitchen cupboards, inspected and in good repair. Knives and other sharp kitchen utensils are stored in a locked drawer. Food supply adequately stored in kitchen fridge. The refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. Appliances in kitchen properly installed and functioning. Stove burners, oven, microwave, washer, and dryer working. There is one refrigerator in the home as well as a kitchen pantry for food storage

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LUXURY ASSISTED LIVING LLC	FACILITY NUMBER: 198320327
	VISIT DATE: 03/09/2023

NARRATIVE

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Smoke detectors and carbon monoxide detector are all hardwire and interconnected, all are operational.
Fire Clearance was approved on 11/02/2022.
All toxins and cleaning supplies are stored and locked inaccessible to clients.
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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 in a locked kitchen cabinet and available for staff use but inaccessible to clients.
Administrator will not be handling cash resources of residents
The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation.
Component III was completed on 03/09/2023 with Dmitry Malyshev to discuss information about how to operate the facility within substantial compliance.

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 Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC809 (FAS) - (06/04)

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