198601570-9-1-2022-11-AS-ASOO-CHATAT-20220814143404

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601570
Report Date: 08/14/2022
Date Signed: 09/01/2022 08:48:53 AM

Document Has Been Signed on 09/01/2022 08:48 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SENIOR LIVING LIFESTYLE- PALOS VERDES		FACILITY NUMBER:	198601570
ADMINISTRATOR:	ROBERT SMITH		FACILITY TYPE:	740
ADDRESS:	3832 PALOS VERDES DRIVE NORTH		TELEPHONE:	(424) 241-2539
CITY:	PALOS VERDES ESTATES	STATE: CA	ZIP CODE:	90274
CAPACITY:	6	CENSUS: 1	DATE:	08/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Robert Smith, Administrator		TIME COMPLETED:	01:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Robert Smith, Administrator and the purpose of today’s visit was explained.

There is currently (1) resident in the facility. (0) residents are ambulatory, (0) are non-ambulatory, (1) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (3) bedrooms, (2) full -bathrooms, shaded back yard & front yard, ramp on back door heading out to back yard & another ramp outside of bedroom #3, laundry room in the attached 2 car garage.

LPA and Robert toured the entire facility inside and out. Documents are posted as mandated. Bedrooms #3 is occupied by resident and contains the mandated furniture. Bedroom #2 is a staff bedroom, until facility receives more residents. The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is not current missing (Health Screening.) Ample supply of perishable and nonperishable food, hot water temperature is 117.5) degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (1) fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SENIOR LIVING LIFESTYLE- PALOS VERDES	FACILITY NUMBER: 198601570
	VISIT DATE: 08/14/2022

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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged, and temperature checked, sanitizer/soap in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted or in folder, Fit testing not completed for staff. Required postings throughout the facility. The resident’s temperatures are checked and logged (twice a day). PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

Technical Advisory (TA) issued. Fit testing was not completed.

An exit interview conducted with Robert Smith, Administrator and copy of report provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 09/01/2022 08:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SENIOR LIVING LIFESTYLE- PALOS VERDES	FACILITY NUMBER: 198601570
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	A health screening as specified in Section 87411, Personnel Requirements - General. This requirement was not met as evidence by: Based on observation and interview, Staff did not have the Health Screening, which poses a potential health,& safety risk to persons in care.
	POC Due Date: 09/01/2022
	Plan of Correction
1 2 3 4	Administrator to provide copy of Health screening or have a new Health Screening performed and send copy to LPA Soto on or before POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2022

LIC809 (FAS) - (06/04)

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