198602210-7-3-2024-11-AS-MLEN-D6TTB4-20240703143432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602210
Report Date: 07/03/2024
Date Signed: 07/03/2024 02:34:43 PM

Document Has Been Signed on 07/03/2024 02:34 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	INDIAN PEAK MANOR		FACILITY NUMBER:	198602210
ADMINISTRATOR:	TORRE, RICARDO DELA		FACILITY TYPE:	740
ADDRESS:	27102 INDIAN PEAK ROAD		TELEPHONE:	(424) 206-2292
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90274
CAPACITY:	6	CENSUS: 6	DATE:	07/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	Ricardo DeLa Torre, Licensee		TIME COMPLETED:	03:05 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 07/03/2024 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced, Required Annual, inspection and met with Licensee Ricardo DeLa Torre and later by Glenda Marquez, Administrator. Six (6) residents and two (2) staff were present during this inspection. The above-mentioned facility is licensed to serve six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility has a hospice waiver for two (2) residents. 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, and a laundry room in the attached two (2) car garage. Administrator Marquez accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. The screen in room four (4) needs to be replaced.Resident bathrooms were checked. Toilets and water faucets worked properly, yet both sinks in bathroom number two (#2) were clogged. Grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Hot water temperature properly measured at 110.3 degrees F which is within title 22 regulations. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked during today's visit. Common areas were clean and clear of hazards, doorways were free of obstructions and a comfortable indoor temperature was maintained at 76.1 degrees F. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food, all stored properly with dates tagged on each storage bag. Knives and potentially dangerous toxins were kept in locked storage cabinet. First-Aid kit was available, with handbook, properly maintained. Two fire extinguishers were observed. One (1) in the kitchen and one (1) in the garage. Both extinguishers were fully charged, last serviced December 09, 2023. LPA tested carbon monoxide detectors and smoke detectors. All devices were connected and functional. LPA observed all medications were centrally stored and inaccessible to residents in care. Report continues, see LIC809C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: INDIAN PEAK MANOR	FACILITY NUMBER: 198602210
	VISIT DATE: 07/03/2024

NARRATIVE

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LPA conducted record reviews which included six (6) residents (R1-R6) service records and two (2) (S1-S2) personnel records and all was observed to be maintained in order and complete. LPA observed all documents are posted as mandated and the last emergency drill was conducted on 06/14/2024.
LPA observed required liability insurance is being maintained, from 04/13/2024 through 04/13/2025.

During today's visit, there were two (2) deficiencies cited. Please see LIC809D.
During today's visit, there were two (2) advisory notes (AN). One AN marked as a technical violation (TV) and the second (2nd) marked as technical assistance (TA)

An exit interview was held with Glenda Marquez, Administrator, and a copy of the facilities' appeal rights, deficiencies, AN's and this report were provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

LIC809 (FAS) - (06/04)

Page: 5 of 5

Document Has Been Signed on 07/03/2024 02:34 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: INDIAN PEAK MANOR	FACILITY NUMBER: 198602210
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. 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 bedroom four (4). Window screen shall be replaced, as the screen does have a hole. Screens shall also be regularly maintained which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2024
	Plan of Correction
1 2 3 4	LPA and Administrator have agreed that the screens will be replaced, and cleaned, as requested on, or prior to, the POC due date. Administrator will send photo/video evidence of the correction to LPA at MARIO.LEON@DSS.CA.GOV.

Type B

Section Cited

CCR

87303(e)(6)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. 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 both sinks in bathroom number two (#2) are currently clogged, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2024
	Plan of Correction
1 2 3 4	The facility has corrected this deficiency while LPA was on-site.

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: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

LIC809 (FAS) - (06/04)

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