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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601627
Report Date: 09/02/2021
Date Signed: 09/02/2021 02:10:25 PM

Document Has Been Signed on 09/02/2021 02:10 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SEAVIEW HOMEFACILITY NUMBER:
198601627
ADMINISTRATOR:MITZI NAKAMURAFACILITY TYPE:
740
ADDRESS:4021 PALOS VERDES DRIVE SOUTHTELEPHONE:
(310) 408-2528
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 4DATE:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:ADMINISTRATOR MITZI NAKAMURATIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA Calderon was met by licensee Mitzi Nakamura and the purpose of today’s visit was explained. The facility is licensed to serve 6 adult clients.
There are currently 0 elder residents in care. ambulatory clients. The facility is a 1-story structure with 3 rooms and 3 bathrooms, dining room, living room, kitchen and patio.
LPA Calderon and staff toured the physical plant. There is no bodies of water or firearm/ammunition on the premises. All client rooms were checked. and are in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. There is adequately PPE stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were not accessible to clients. Smoke detectors were had wires, Carbon Monoxide was found in the facility and is in working condition.

During the visit, LPA observed the facility infection control practices. LPA did observe screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff were wearing face coverings, an isolation room is confirmed for the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.



During today’s visit there was deficiencies under California code of regulation title 22, division 6, chapter 8.

Exit interview held and appeal rights provided. A copy of the report was provided to licensee Mitzi Nakamura.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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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