198320487-7-8-2024-11-AS-MLEN-D6YQHA-20240708121048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320487
Report Date: 07/08/2024
Date Signed: 07/08/2024 12:11:46 PM

Document Has Been Signed on 07/08/2024 12:11 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:	PEPPERWOOD VILLA		FACILITY NUMBER:	198320487
ADMINISTRATOR:	UMANA, JOSE		FACILITY TYPE:	740
ADDRESS:	4224 PEPPERWOOD AVE		TELEPHONE:	(562) 477-5797
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	6	CENSUS: 0	DATE:	07/08/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Jose Umana, Administrator		TIME COMPLETED:	12:29 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 07/08/2024 Licensing Program Analyst (LPA) Mario Leon conducted an announced visit to this home. LPA was met by Jose Umana, Administrator and LPA explained the purpose of today’s prelicensing inspection visit. An application was submitted to CCLD on 04/15/2024 in the initial license application for a Residential Facility for the Elderly, ages 60 years and above. The applicant requested a capacity of six (6) individuals, of which six may be (6) non-ambulatory and zero (0) bedridden residents. Structure: The home is a one-story, residential unit, without any garage and is located in a residential neighborhood. The home consists of five (5) bedrooms, two (2) bathrooms, one (1) Detached Accessory Dwelling Unit (ADU) for staff with one (1) staff toilet. The home includes a living, dining, kitchen area which includes a laundry area. The living room did not include a fireplace. The living area included recliner seating. The kitchen has a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. Bedrooms Residents: The facility has five (5) bedrooms for residents. This includes all five (5) bedrooms for non-ambulatory residents. All rooms include a twin-size bed, one (1) chair, one (1) night stand, and one (1) table lamp. All bedrooms are equipped with a ceiling light. Four (4) rooms include a dresser and closet, one (1) shared room is fitted with a stand-alone closet, which complies with the requirement of 8 cubic feet of personal storage space. The rooms also include wall night lights. REPORT CONTINUES, SEE LIC809C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

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: PEPPERWOOD VILLA	FACILITY NUMBER: 198320487
	VISIT DATE: 07/08/2024

NARRATIVE

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Bedrooms Staff:
Detached ADU is designated for live-in staff, with one (1) toilet included within.
Bathrooms:
The home has two (2) bathrooms. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.
Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, waterproof mattress pads, fitted sheets, flat sheets and blankets. An adequate supply of linen is stored in the northernmost hall closet .
Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There are two (2) fire extinguishers located in the entryway and kitchen, both mounted on the wall, and are fully charged as of 05/07/2024 and are accessible to staff and residents. A telephone line is available in the facility at 562.354.6354. Emergency supplies and Personal Protective Equipment supplies are stored in the central closet. The applicant has an approved Infection Control Plan on file.
Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Cutlery has been supplied adequately. Knives and other sharp kitchen utensils are stored in a locked kitchen cabinet. Food supply is adequately stored in kitchen cabinets and consists of 7-day supply of non-perishable canned goods. The refrigerator is adequately stocked for, at least, 2-days of perishable foods.
Smoke Detectors:
Seven (7) smoke detectors and two (2) carbon monoxide detectors were observed throughout the interior space. All units were tested and are in working order. One (1) Carbon monoxide is located in the dining room and one (1) is located in northern hallway.
Toxins:
All toxins and detergents are locked and stored under the kitchen sink cabinet.
Appliances:
Stove burners, microwave, washer, and dryer are in working order. There is one (1) refrigerator in the home. The refrigerator measured a temperature of at least 40 degrees Fahrenheit for appropriate food storage. There is also one (1) coffee maker and one (1) toaster, both in working order. The residential area has a central cooling/heating system.
REPORT CONTINUES, SEE LIC809C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

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: PEPPERWOOD VILLA	FACILITY NUMBER: 198320487
	VISIT DATE: 07/08/2024

NARRATIVE

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Water Temperature:
The water temperature is 106.9 degrees F located in the kitchen and water temperature averaged at
105.7 degrees F in the two (2) bathrooms.
Medications, First-Aid Kit & Book:
A first aid kit is stored in the central closet and was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The resident's medications will be stored in a metal cabinet, locked and inaccessible to residents in care, located in the living room area.
Resident & Staff Files:
The applicant is not handling the cash resources for residents. Records of staff and residents will be stored in a metal cabinet in the dining room area.
Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the resident's use all stored in the living room, below the TV unit.
Pool/Jacuzzi & Pets:
There are no pets located on-site and the above-mentioned facility does not have any bodies of water on-site.

The component III power point was held with Jose Umana and Elsa Roman and both acknowledged the points discussed .

An exit interview was conducted with Jose Umana, and a copy of this report has been provided to the applicant. LPA Leon will submit a copy of this facility evaluation report 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 the CAU Analyst assigned to their application.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

LIC809 (FAS) - (06/04)

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