198601570-8-28-2024-11-AS-SLEO-D8KTJP-20240828144641

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601570
Report Date: 08/28/2024
Date Signed: 08/28/2024 02:46:51 PM

Document Has Been Signed on 08/28/2024 02:46 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: 3	DATE:	08/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Licensee/Administrator - Robert Smith		TIME COMPLETED:	03:00 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 08/28/2024 at around 10:00 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 3 residents are currently residing in this facility. 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 (has been converted to 2 rooms and is under construction), and 1 backyard patio area.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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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Document Has Been Signed on 08/28/2024 02:46 PM - 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
EL SEGUNDO ASC, 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: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having clutter in the backyard, walkways around the home, living room, kitchen/dining and facility's back door leading to the trail is in disrepair room which poses a potential health and safety to persons in care.
	POC Due Date: 09/24/2024
	Plan of Correction
1 2 3 4	Licensee will declutter the backyard, walkways around the home, living room, and kitchen/dining room areas. Licensee will discard items on Palos Verdes Estates bulky trash pick up on 09/18/2024. Licensee will fix back door. Licensee will email pictures of proof of corrections to Socorro.Leandro@dss.ca.gov.

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SENIOR LIVING LIFESTYLE- PALOS VERDES	FACILITY NUMBER: 198601570
	VISIT DATE: 08/28/2024

NARRATIVE

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Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. LPA observed clutter (items that were in the garage such as, bikes and several household items) in the backyard, walkways around the home, and the facility’s back door leading to the trail is in disrepair. 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.

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. LPA observed clutter (miscellaneous household items on counter-tops, office table, and floor) in the living room, dining/kitchen area.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 08/28/2024

NARRATIVE

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1 staff record was reviewed, 1 out of 1 staff record had required documentation.

3 resident records were reviewed and, 3 out of 3 resident records had required documentation.

Technical Assistance is being issued regarding California Code of Regulation (CCR), Title 22, Alteration to Existing Building, 87305(a). Licensee will connect with his Licensing Program Analyst, Mario Leon.
1) Licensee will have their local authority (city) inspect their new construction and receive approval for their new construction.
2) Licensee will email approval of their new construction and an updated facility sketch (LIC 999) to Mario.Leon@dss.ca.gov.

A deficiency is being cited based on LPA observation in accordance with the CCR, Title 22. A violation regarding CCR, Title 22, Maintenance and Operation, 87303(a).

An exit interview was conducted, a copy of this report was left with the Licensee along with their appeal rights.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

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