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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320474
Report Date: 08/13/2026
Date Signed: 08/13/2026 02:26:53 PM

Document Has Been Signed on 08/13/2026 02:26 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:FAMILY CONNECT MEMORY CARE PALOS VERDESFACILITY NUMBER:
198320474
ADMINISTRATOR/
DIRECTOR:		KRISTINE SIMONIANFACILITY TYPE:
740
ADDRESS:28873 BLYTHEWOOD DRTELEPHONE:
(310) 383-1877
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 6DATE:
08/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Administrator Kristine SimonianTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 08/13/26, at 12:30 Pm, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced annual required inspection visit. LPA met with House Manager-Roxanna Cabrera and Administrator Kristine Simonian and they were explained the purpose of today’s visit.

The facility is licensed to serve (6) non-ambulatory residents ages 60 and over in rooms #1, 2, 3, and 4, with a hospice waiver for two (2). Currently, the home has (6) residents. The facilities annual fees are current.

The facility is a single-story r home located in a residential neighborhood. The home consists of the following: 4 bedrooms, 2 ½ bathrooms, kitchen, living room, dining area, laundry area, attached garage, and a backyard.

At 12:40 PM, the department reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings which appeared to be up to date.

The department also reviewed six (6) residents’ files for admission agreements, updated physician reports, and needs and services plan which appeared to be up to date.


At 1:30pm, the department and Kristine toured the physical plant. There were no bodies of water or obstructions on the premises inside or outside.



LPA inspected a total of four (4) bedrooms and two-half 2-1/2 bathrooms. The beds and bedding supplies appeared to be in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed.
Stephanie Cifuentes
Bernadette Allen
DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: FAMILY CONNECT MEMORY CARE PALOS VERDES
FACILITY NUMBER: 198320474
VISIT DATE: 08/13/2026
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The bathrooms were in good condition and operational. The water temperature ranged from 105°F to 120. °F, and the facility temperatures ranged from 72°F to 75°F.

LPA observed that he facility appeared to be clean, sanitary, and appropriately furnished and there is storage areas for personal hygiene were in place.

Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care.

The kitchen was inspected, and there was a 5-day supply of perishable and a 7day supply of non-perishable food items available, which was adequately maintained/stored.

The fire extinguishers, carbon monoxide detectors and smoke detectors were fully charged and operable. The last fire drill was conducted on July 6,2026.


Based on the observations made during today’s visit, no deficiencies were cited.

An exit interview was conducted, and this report was discussed and provided to Kristine Simonian at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Bernadette Allen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC809 (FAS) - (06/04)
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