198320327-3-6-2024-11-AS-RCLD-D34QYW-20240306113548

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320327
Report Date: 03/06/2024
Date Signed: 03/06/2024 11:36:03 AM

Document Has Been Signed on 03/06/2024 11:36 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 ASC, 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: 0	DATE:	03/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:46 AM
MET WITH:	Administrator Dmitry Malyshev		TIME COMPLETED:	11:50 AM

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On 03/06/2024 at 9:45 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – Annual Inspection and met with Administrator Dmitry Malyshev. Annual Facility Fees are current.

Facility is licensed to serve 6 non-ambulatory residents age 60 and above. One may be bedridden in room 2 only. The facility has a hospice waiver approved for 3.

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.

Administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, and warning signs are prominently identified in the kitchen and in the bathroom. The second shower is under currently under construction. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Knives and toxics were kept in locked storage cabinet. First Aid kit was available. Licensee tested all carbon monoxide detectors and smoke detectors located in the facility. Both devices were functional and interconnected.

Deficiencies are being cited based on LPA observation and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding 87204 Limitations - Capacity and Ambulatory Status. The Administrator rented three of the bedrooms out to private individuals. There are no residents in care.

An exit interview was conducted, plans of corrections were developed and reviewed, and technical assistance provided. A copy of this report and appeal rights were discussed and left with the Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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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Document Has Been Signed on 03/06/2024 11:36 AM - It Cannot Be Edited

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: LUXURY ASSISTED LIVING LLC	FACILITY NUMBER: 198320327
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87204(a)

Limitations -Capacity and Ambulatory Status

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above which poses a potential safety or personal rights risk. The administrator rented out bedrooms 1, 2, and 4 to private individuals (associated to the facility number).
	POC Due Date: 03/21/2024
	Plan of Correction
1 2 3 4	The administrator will submit proof of correction to regina.cloyd@dss.ca.gov by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC809 (FAS) - (06/04)

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