198601887-11-11-2023-11-AS-DESA-CXH2ZS-20231111165050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601887
Report Date: 11/11/2023
Date Signed: 11/11/2023 04:50:55 PM

Document Has Been Signed on 11/11/2023 04:50 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	VELEZ CARE HOME		FACILITY NUMBER:	198601887
ADMINISTRATOR:	CHILLY LYN NAVARRO		FACILITY TYPE:	740
ADDRESS:	2120 VELEZ DRIVE		TELEPHONE:	(213) 880-1629
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	4	CENSUS: 4	DATE:	11/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:02 PM
MET WITH:	Staff #1		TIME COMPLETED:	05:00 PM

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On 11/11/2023 at 2:00 pm Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection.

LPA was met with S#1 and the purpose of today’s visit was explained. The Residential Care Facilities for the Elderly (RCFE) is licensed to serve (4) non ambulatory residents age (60) sixty and above, approved hospice waiver for (2) two residents. There are currently (4) residents in the facility. Harbor Regional Center placement, three (3) residents are ambulatory, one (1) are non-ambulatory, zero (0) bedridden.

The facility is a single-story structure located in a residential neighborhood. It consists of four (4) bedrooms, two (2) full bathrooms, shaded back yard, front yard, laundry room, family room, living room/office, kitchen, empty pool, and attached two (2) car garage.LPA and S#1 toured the entire facility inside and out. Documents are posted as mandated. Bedrooms #1-#4 are occupied by residents and contain the mandated furniture. The (2) bathrooms have grab bars and non-skid mats and are clean and operational. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detectors were in compliance and operational. No firearms are stored at facility and no bodies of water present.

A reviewed of Medication Records Administration (MAR) was observed to be maintained in order and accurate. Medications are stored, locked and inaccessible to residents. Resident files along with medications are current. Staff files is current. Ample supply of perishable and nonperishable food, hot water temperature is (107.1) degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (2) fire extinguisher is fully charged. Continued on LIC-809C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VELEZ CARE HOME	FACILITY NUMBER: 198601887
	VISIT DATE: 11/11/2023

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Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage.

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.

Two Technical Advisory (TA) issued.

Physical Plant/Environmental Safety - Technical Assistance: 87307(d)(4)
Resident Rights/Information - No Deficiency: 87468(c)(2)(A)

An exit interview conducted with S#2 and a hard copy of report provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2023

LIC809 (FAS) - (06/04)

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