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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320523
Report Date: 07/06/2026
Date Signed: 07/06/2026 04:40:25 PM

Document Has Been Signed on 07/06/2026 04:40 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:CECILE'S PLACEFACILITY NUMBER:
198320523
ADMINISTRATOR/
DIRECTOR:		POLLARD, CHELSEAFACILITY TYPE:
740
ADDRESS:4369 HUNTLEY AVETELEPHONE:
(310) 902-4522
CITY:CULVER CITYSTATE: CAZIP CODE:
90230
CAPACITY: 6CENSUS: 5DATE:
07/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Chelsea Pollard (Adminstrator)TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 07/06/2026 at 11:40am, the Department conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the annual inspection. Licensing Program Analyst (LPA) Zina Brown met with Chelesa Pollard (Administrator) and the purpose of the visit was discussed. Facility is licensed to serve 6 non-ambulatory residents of which in one maybe bedridden. All rooms approved for bedridden/non-ambulatory and a wavier granted for 3 hospice residents. 4 residents are diagnosed with dementia and 3 are receiving hospice care services. The facility does not handle any of the residents’ money.

The facility holds a Administrator Certification for Chelsea Pollard #6073436740 (valid 01/01/2025 - 01/02/2027). The facility annual fees are a balance of $495.00 due June 26, 2026. LPA provided the facility with PIN #788097 with the option to make payment online. The facility liability insurance with Kinsale Insurance Company (Policy #0100391140-0) valid 08/13/2025 - 08/13/2026 with general liability at $1,000,000 and aggregate limit at $3,000,000.

The home is a single story home consisting of: (4) resident bedrooms, (2) Full bathroom a half bathroom in the garage, den/living room, kitchen with a formal dining area, laundry area that houses a washer and dryer (located in the attached garage) and an outdoor shaded patio area.

On 07/06/2026, between the hours 12:00pm - 12:22pm, LPA toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured at 118.F in kitchen, in bathroom 1 at 114.6F and in bathroom 2 at 116.6F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2026
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: CECILE'S PLACE
FACILITY NUMBER: 198320523
VISIT DATE: 07/06/2026
NARRATIVE
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On 07/06/2026, between the 12:30pm - 2:45pm of LPA conducted a records review of (4) resident records, (0) staff records, (4) clients Personal & Incidental Records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit.

Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); the Department observed the following deficiencies:

1. Resident 3 (R3) is utilizing half bed rails is no longer on hospice. Upon record review of R3's file did not have a physicians order on file for the use half bed rails.

2. All records for 5 staff and for 5 staff are incomplete such as
LIC 501, LIC 503 with TB Test, First Aid/CPR, Annual Staff Training for S1, S2, S3, S4, & S5
S2 - S5 not being associated to the facility at the time of unannounced annual inspection.

3. All records for residents (Resident 1 - Resident 5) are incomplete such
LIC 601, 603, LIC 613, LIC 625 and Admission Agreement is missing for R1, R2, R3, R4, R5
LIC 602 with TB Test Results is missing for R1, R5

4. Upon medication review, LPA observed not listed on the MAR
6 PRN's for R2 not listed on the MAR
R4's Furosemide not listed on the MAR
R5's medication not listed on the MAR

5. The Department asked for the last date of the last emergency drill. The administrator stated they have had a emergency drill about 3 months ago but did not have documentation of the time and date drill was conducted.

An exit interview was conducted Chelsea Pollard (Administrator), and a copy of Report and Appeal Rights provided.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2026 04:40 PM - It Cannot Be Edited


Created By: Zina Brown On 07/06/2026 at 03:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CECILE'S PLACE
FACILITY NUMBER: 198320523

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for 4 out of 5 staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2026
Plan of Correction
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The facility submit (4) LIC 9182 Criminal Background Clearance Transfer Request for S2 Raymar Arana, S3 Robert Sinclair, S4 Patrice Antonio, S5 Majorie Brown to the Department via email at zina.brown@dss.ca.gov by POC due date for the employees S2, S3, S4, & S5 to be associated in Guardian.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Zina Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2026 04:40 PM - It Cannot Be Edited


Created By: Zina Brown On 07/06/2026 at 03:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CECILE'S PLACE
FACILITY NUMBER: 198320523

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2026
Plan of Correction
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The facility will document the time & date of the next emeregency disaster drill and via email at zina.brown@dss.ca.gov by POC due date
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above for 1 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2026
Plan of Correction
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The licensee will remove half-bedrails and or obtain a written order from a physician indicating the need for the postural support for the following Resident 3 (R3) Daniel Donovan, and submit proof to the department via email Zina.Brown@dss.ca.gov by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Zina Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2026 04:40 PM - It Cannot Be Edited


Created By: Zina Brown On 07/06/2026 at 03:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CECILE'S PLACE
FACILITY NUMBER: 198320523

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)(A-F)
(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring a record of centrally stored prescription medications for each resident is maintained ...(A-F) records for centrally stored medication…
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Department identified undocumented on the medication administrations record, for R2 - 6 PRN’s & Loratadine, R4’s Furosemide, & all of R5’s medication indicating medications were not documented as required, which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 07/27/2026
Plan of Correction
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The Administrator will ensure all entries of medication for all residents recorded on the MAR & must be signed & dated daily. The administrator will submit proof of update MARs for R2, R4, R5 and email proof to LPA Brown at Zina.Brown@dss.ca.gov by POC due date
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above out for 5 out of 5 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2026
Plan of Correction
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The facility will submit proof of LIC 501, LIC 503 with TB Test, First Aid/CPR, Annual Staff Training for S1, S2, S3, S4, S5 via email at zina.brown@dss.ca.gov by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Zina Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2026


LIC809 (FAS) - (06/04)
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