198320397-10-26-2023-11-AS-AINZ-CWYN8J-20231026101424

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320397
Report Date: 10/26/2023
Date Signed: 10/26/2023 10:14:33 AM

Document Has Been Signed on 10/26/2023 10:14 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:	DIVINE LIFE GUEST HOME		FACILITY NUMBER:	198320397
ADMINISTRATOR:	ROSALDO, RODRIGO		FACILITY TYPE:	740
ADDRESS:	1711 W. 243RD ST.		TELEPHONE:	(310) 310-1851
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY:	6	CENSUS: 0	DATE:	10/26/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Rodrigo Rosaldo-Licensee		TIME COMPLETED:	10:14 AM

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On 10/26/23 Licensing Program Analysts (LPA) Alfonso Iniguez conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with authorized licensee: Rodrigo Rosaldo.

The licensee has applied for a license to serve (6) elderly residents ages 59 and older. The fire clearance is approved for (5) non-ambulatory and (1) bedridden resident in room #4. Approved Hospice waiver for (6). The licensee plans to advertise for Special Care Programs for Dementia Residents.

A tour of the Kitchen, Dining Room, Living Room, (5) Bedrooms, (1) Staff Room, (2) Bathrooms, Garage, Storage for all supplies, Back Yard, Ramps and Outside table with shade.

The following was observed during this visit:

MEDICATIONS

There is a locked centralized storage area for Resident medications.

PHYSICAL PLANT

Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 73°F. degrees. Open porches, and areas of potential hazard are well-lit. Smoke alarms operate properly. Carbon monoxide detectors operate properly.

Report continues on LIC 809 C...

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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: DIVINE LIFE GUEST HOME	FACILITY NUMBER: 198320397
	VISIT DATE: 10/26/2023

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BEDROOMS

There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair.

Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client. There is a chair and lamp for each client and at least one (1) night stand per two (2) clients.

BATHROOMS

There is at least one (2) toilet and washbasin per six (6) clients, family, and personnel. There is at least one (2) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is 113° Fahrenheit. Bathroom is located near client bedrooms. There are night-lights in the hallways outside non-private bathrooms.

SUPPLIES

There are client personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. 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(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0° Fahrenheit. Refrigerator is a maximum of 45° Fahrenheit. A seven (7) day supply of non-perishable food is present. There are enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

Report continues on LIC 809 C...

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

Page: 2 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DIVINE LIFE GUEST HOME	FACILITY NUMBER: 198320397
	VISIT DATE: 10/26/2023

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RECORDS

There is confidential storage of personnel records at the facility. There is confidential storage of client 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 is at least one common room available to clients for visitors.

Report continues on LIC 809 C...

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DIVINE LIFE GUEST HOME	FACILITY NUMBER: 198320397
	VISIT DATE: 10/26/2023

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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.

PRE-LICENSING CHECKLIST

N/A

During today’s inspection LPA found the following correction(s) are required:

-Currently room #1 and #2 are connected through a door, this layout does not reflect the facility sketch submitted to CAB.

-LPA did not see enough board games for residents.

Correction(S) needed:

Licensee will ensure to submit a new facility sketch to CAB.

Licensee will ensure a variety of board games are available at the facility.

Exit interview conducted with Rodrigo Rosaldo/Administrator-Licensee.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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