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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320478
Report Date: 02/07/2025
Date Signed: 02/07/2025 11:00:38 AM

Document Has Been Signed on 02/07/2025 11:00 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:AVOCET AT PLAYA VISTAFACILITY NUMBER:
198320478
ADMINISTRATOR/
DIRECTOR:		MCGEVNA, KEITH MFACILITY TYPE:
741
ADDRESS:12490 FIELDING CIRCLETELEPHONE:
(424) 216-7788
CITY:PLAYA VISTASTATE: CAZIP CODE:
90094
CAPACITY: 286CENSUS: 227DATE:
02/07/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Executive Director Keith McGevnaTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On 02/07/2025, Community Care Licensing Division (CCLD) Staff conducted a case management - incident visit at the above facility. CCLD Staff spoke with the Executive Director Keith McGevna over the phone and explained that the purpose of the visit was to collect information about Resident #1's (R1) incident on 01/09/2025. The facility emailed the report to cclascpelsegundoro@dss.ca.gov on 01/16/2025 1:32 PM. CCLD Staff collected resident and facility records.

An exit interview was conducted and a copy of this report was left with the Director of Assisted Living Chelsea Navarro, RN.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
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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