198320375-11-20-2023-11-AS-EGOZ-CXS2PA-20231120163402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320375
Report Date: 11/20/2023
Date Signed: 11/20/2023 04:34:12 PM

Document Has Been Signed on 11/20/2023 04:34 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:	CIELA		FACILITY NUMBER:	198320375
ADMINISTRATOR:	TBH		FACILITY TYPE:	740
ADDRESS:	17310 WEST VEREDA DELA MONTURA		TELEPHONE:	(917) 667-5303
CITY:	PACIFIC PALISADES	STATE: CA	ZIP CODE:	90272
CAPACITY:	100	CENSUS:	DATE:	11/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Roney Shram		TIME COMPLETED:	04:45 PM

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On 11/20/23 Licensing Program Analysts (LPA) Elvira Gonzalez, (LPA) Socorro Leandro, (LPA) Regina Cloyd conducted a pre-licensing evaluation for an RCFE (Residential Care Facility for the Elderly) facility type. Today’s pre-licensing evaluation was conducted with licensee Rony Shram.

The licensee has applied for a license to serve (100) age range 60 and over adults. The fire clearance is approved for (80) non-ambulatory and (20) bedridden residents.

LPA’s toured facility Kitchen, Dining Room, Living Room areas, (82) Bedrooms, (99) Bathrooms, Garage, and botanical garden, patios with shaded areas. LPA’s toured the lobby, lounge, beauty bar, gym, theater room, indoor pool and several common spaces. LPA’s observed sufficient storage areas for kitchen supplies, linens, medications (secured) and chemicals (secured).

LPA observed the following during this visit:

MEDICATIONS

There is a locked centralized storage area for Resident medications.

PHYSICAL PLANT

LPA’s observed the facility is clean, sanitary, and in good repair. Indoor and outdoor passageways, stairways, open areas, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68° degrees and 85° degrees. Open patios, and areas of potential hazard are well-lit. Carbon monoxide/Smoke detectors operate properly.

BEDROOMS

All rooms were inspected and are compliant with California code of regulations title 22.

Continued on LIC 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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: CIELA	FACILITY NUMBER: 198320375
	VISIT DATE: 11/20/2023

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BATHROOMS

There are plenty toilets and washbasins for clients, family, and personnel. There are plenty showers for clients, family, and personnel. Hot water temperature is between 105°-120° degrees Fahrenheit. Bathrooms are located inside client bedrooms and common areas. Public restroom calling system is operational.

SUPPLIES

There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths.

FOOD SERVICE

Dining room is near kitchen. Refrigerator and freezer are clean and have the capacity to store at least two (2) days of perishable foods. There is storage for seven (7) day supply of non-perishable food. There are enough tableware, tables, dishes, and utensils. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

RECORDS

There is confidential storage for personnel records at the facility. There is storage for Resident confidential information and records at the facility.

Continued on LIC 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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: CIELA	FACILITY NUMBER: 198320375
	VISIT DATE: 11/20/2023

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RECORDS

There is confidential storage for personnel records at the facility. There is storage for Resident confidential information and records at the facility.

ADMINISTRATION

The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings.

ACTIVITIES

There is an outdoor activity space with a shaded area and furnished for outdoor use. There are at least 3 common areas available to clients for visitors. There are activities scheduled during the current month.

MISCELLANEOUS

There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries.

Continued LIC 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: CIELA	FACILITY NUMBER: 198320375
	VISIT DATE: 11/20/2023

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MISCELLANEOUS

LPA’s observed a sign-in/sanitation station at the facility entry. There is hand sanitizer located at the entrance of the facility. Facility has screening process for all visitors, sanitizer/soap, paper towels, and additional PPE supplies are stored inside the facility.

LPA Cloyd conducted the Component III Orientation with the Licensee and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC809 (FAS) - (06/04)

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