198320398-4-3-2024-11-AS-AINZ-D3YSY9-20240403141711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320398
Report Date: 04/03/2024
Date Signed: 04/03/2024 02:17:44 PM

Document Has Been Signed on 04/03/2024 02:17 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:	PENINSULA POINTE BY COGIR		FACILITY NUMBER:	198320398
ADMINISTRATOR: ADMINISTRATOR/ DIRECTOR:	KITAGAWA, DESIREE		FACILITY TYPE:	740
ADDRESS:	27520 HAWTHORNE BOULEVARD		TELEPHONE:	(310) 697-6236
CITY:	ROLLING HILLS ESTATE	STATE: CA	ZIP CODE:	90274
CAPACITY: 121		CENSUS: 0	DATE:	04/03/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN: TIME VISIT/ INSPECTION BEGAN:	09:53 AM
MET WITH:	Desiree Kitagawa-Administrator		TIME COMPLETED: TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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On 4/3/24 Licensing Program Analysts (LPA’s) Alfonso Iniguez and Wendy Gibbs conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with authorized licensee: Desiree Kitagawa/Administrator.

The licensee has applied for a license to serve (121) elderly residents age range 60 and over. The fire clearance is approved for (101) non-ambulatory and (20) bedridden where twenty (20) can be bedridden on first floor #116-120, 123-127, 135-137 and 147. Basement and second floor for non-ambulatories only. Approved hospice waiver for (15).

A tour of the entire facility was conducted: basement floor, first floor, second floor, kitchen, common areas, outside of facility, medication room, records room, generator bathrooms, activity program, weekly menus.

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 LIC 809C.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

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: PENINSULA POINTE BY COGIR	FACILITY NUMBER: 198320398
	VISIT DATE: 04/03/2024

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BEDROOMS

There is a space for client’s own furniture that will accommodate a bed, a chair, a nightstand, a lamp, reading lights and a chest of drawers.

BATHROOMS

There is at least (95) toilet and washbasin per six (6) clients, family, and personnel. There is at least (87) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is between 105F°. and 120F°. Bathrooms are located inside clients’ bedrooms. There are nightlights 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.

RECORDS

There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

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: PENINSULA POINTE BY COGIR	FACILITY NUMBER: 198320398
	VISIT DATE: 04/03/2024

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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 will be 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.

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 commercial 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. Copy of liability insurance was email to LPA during this visit.

DELAY EGGRESS and SECURE PERIMETER

Delay egresses are located on the 1^st floor memory care entry and courtyard gate and stairwell access LPA Gibbs observed the functioning of it. Facility will use a Wander guard system as perimeter to secure residents with cognitive issues. Check points are located at exits, it will signal an alarm and a signal to the facility signal system, LPA Iniguez observed the functioning of the system.

During this pre-licensing inspection, LPAs did not find corrections are needed. LPA Iniguez 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. If the applicant has questions regarding the status of the application, they have been instructed to communicate with their assigned CAU Analyst.

Exit interview conducted with Desiree Kitagawa/Administrator

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC809 (FAS) - (06/04)

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