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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601627
Report Date: 12/16/2022
Date Signed: 12/16/2022 11:58:44 AM


Document Has Been Signed on 12/16/2022 11:58 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
EL SEGUNDO, 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: 0DATE:
12/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH: Mitzi Nakamura - LicenseeTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA Leon was met by licensee Mitzi Nakamura and the purpose of today’s visit was explained. The facility is licensed to serve 6, non-ambulatory, elderly clients (60yrs+).
There are currently 0 residents in care. The facility is a one-story structure with 3 rooms and 3 bathrooms, dining room, living room, kitchen and patio and is located in a residential neighborhood.
LPA Leon and licensee toured the physical plant. There are 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 was adequate PPE stocked at the time of visit. Bathrooms were found to be without warm water, yet 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 hard wired, Carbon Monoxide was found in the facility and needs to be upgraded.

During the visit, LPA observed the facility infection control practices. LPA did observe screening protocols for visitors, staff and residents, sanitizing stations were present (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 Licensee to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PINs) for any updates relating to COVID-19 guidance.



During today’s visit there were no deficiencies sited, there were technical violations sited. See LIC-9102.

Exit interview held. A copy of the report was provided to Licensee Mitzi Nakamura.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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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