198601570-1-6-2024-11-AS-SLEO-CZ8T3M-20240106132233

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601570
Report Date: 01/06/2024
Date Signed: 01/06/2024 01:22:43 PM

Document Has Been Signed on 01/06/2024 01:22 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, 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: 4	DATE:	01/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Licensee/Administrator - Robert Smith		TIME COMPLETED:	01:40 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 1/6/2023 at around 10:20 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Licensee/Administrator Robert Smith. LPA explained the purpose of the visit and was accompanied by Licensee inside and outside the facility during this inspection. This facility is licensed to serve 6 non-ambulatory adults ages 60 and above, of which 1 may bedridden. This facility is approved for 4 hospice residents. A total of 4 residents are currently residing in this facility, of which 1 is a non-ambulatory resident. The Annual Licensing Fees are current. The facility is a one-story house located in a residential street. The home consists of 3 resident bedrooms, 2 bathrooms, 1 living room, 1 dining/office room, 1 kitchen, 1 attached garage, and 1 backyard patio area with shaded seating. Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SENIOR LIVING LIFESTYLE- PALOS VERDES	FACILITY NUMBER: 198601570
	VISIT DATE: 01/06/2024

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
26
27
28
29
30
31
32

LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. First aid kit is fully stocked. Smoke and carbon monoxide detectors were in compliance and operational. The fire extinguisher is in the kitchen area and was last serviced on 12/08/2023. There is a videoconferencing device (laptop) and a land line telephone dedicated for client use in the office area.

3 out of 3 resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

1 staff record was reviewed, 1 out of 1 staff record had a Criminal Record Clearance, Job Application, and signed Employee Rights.

4 resident records were reviewed and, 4 out of 4 resident records had Admission Agreements, Medical Assessments Consent Forms, Weight Record, Emergency Information, Appraisal & Needs Service Plan, Tuberculosis Test, Centrally Stored Medication Destruction Record, and Personal Rights.

No deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted, and a copy of this report was left with the Licensee.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024

LIC809 (FAS) - (06/04)

Page: 6 of 6