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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320345
Report Date: 02/14/2024
Date Signed: 02/14/2024 02:31:41 PM


Document Has Been Signed on 02/14/2024 02:31 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:OCEAN VISTA RESIDENTIAL CAREFACILITY NUMBER:
198320345
ADMINISTRATOR:DRAPEAU, MAY I.FACILITY TYPE:
740
ADDRESS:2900 S. ANCHOVY AVENUETELEPHONE:
(424) 201-5104
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY:6CENSUS: 5DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Cheryl Cambay-LicenseeTIME COMPLETED:
02:30 PM
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On 2/14/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Cheryl Cambay / Licensee. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) non-ambulatory residents ages 60 and above. Approved hospice waiver for (2).

The facility is a single-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, (2) 3/4 bathrooms & (1) 1/2 bathroom, living room, kitchen, dining room/office area/extra family room, breakfast nook, shaded area, ramps on the back porch and north side of house, indoor and outdoor activity area, laundry room and an attached garage.

LPA Iniguez toured the physical plant with licensee. There were no bodies of water or obstructions on the premises. A total of (4) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected the carbon monoxide detectors combo were in operable condition. The water temperature properly measured between: 105°F-120°F: Kitchen 107.1°F, Bathroom #1:107.7°F, Bathroom #2:108.1°F.

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: OCEAN VISTA RESIDENTIAL CARE
FACILITY NUMBER: 198320345
VISIT DATE: 02/14/2024
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LPA Iniguez observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed. sharps objects and cleaning supplies were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available at the properly. All fire extinguishers were charged and were operable. A review of (3) residents' service files, (3) staff personnel files were reviewed. LPA checked (3) Medication Administration Records (MAR) and no discrepancies were found. The first AID kit was checked. Last facility disaster drill was: 3/7/2023.

LPA observed the facility's infection control practices. A copy of the liability insurance was given to LPA during the visit.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.




An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Cheryl Cambay /Licensee.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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