<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320398
Report Date: 05/08/2024
Date Signed: 05/08/2024 02:24:49 PM

Document Has Been Signed on 05/08/2024 02:24 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 COGIRFACILITY NUMBER:
198320398
ADMINISTRATOR/
DIRECTOR:		KITAGAWA, DESIREEFACILITY TYPE:
740
ADDRESS:27520 HAWTHORNE BOULEVARDTELEPHONE:
(310) 697-6236
CITY:ROLLING HILLS ESTATESTATE: CAZIP CODE:
90274
CAPACITY: 121CENSUS: 8DATE:
05/08/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:38 PM
MET WITH:Desiree Kitagawa/Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
02:21 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/8/24, Licensing Program Analyst-LPA Alfonso Iniguez conducted an unannounced post-licensing visit and met with Desiree Kitagawa/Executive Director, and the purpose of the visit was explained. The facility is licensed to serve (121) elderly residents ages 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). Currently, the facility has (8) residents. Per CAB, the following item(s) need to be reviewed during the post-licensing inspection:

· Personnel Policies

· Abuse Reporting Procedures

· In-Service Training and Medication Procedures

During the visit, LPA and Executive Director collaborated closely, reviewing the policies and procedures the facility submitted to CAB on initial application of license. The facility also has current policies available upon request. A joint tour of the facility was conducted.


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 Desiree Kitagawa/Executive Director.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1