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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602210
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:53:42 PM


Document Has Been Signed on 12/21/2023 03:53 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:INDIAN PEAK MANORFACILITY NUMBER:
198602210
ADMINISTRATOR:TORRE, RICARDO DELAFACILITY TYPE:
740
ADDRESS:27102 INDIAN PEAK ROADTELEPHONE:
(424) 206-2292
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90274
CAPACITY:6CENSUS: 6DATE:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Administrator Glenda MarquezTIME COMPLETED:
04:15 PM
NARRATIVE
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On 12/21/2023 at 9:56 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with Administrator Glenda Marquez. Six (6) residents and two (2) staff were present during this inspection.

Facility is licensed to serve six (6) non-ambulatory, 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 (4) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room in the attached 2 garage..

Administrator 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.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 107.2 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. Two fire extinguishers, last serviced December 9, 2023 was observed in the kitchen and garage area. LPA tested all carbon monoxide detectors and smoke detector. Both devices were functional.

Continue to LIC-809C

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6


Document Has Been Signed on 12/21/2023 03:53 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: INDIAN PEAK MANOR
FACILITY NUMBER: 198602210

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for three out of five resident which poses a potential health rights risk to persons in care. LPA did not observe an annual medical assessments (LIC 602) nor reappraisals for residents #3, #4, and #5 diagnoised with dementia. LPA and staff reviewed the files together.
POC Due Date: 01/19/2024
Plan of Correction
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Glenda Marquez will email updated medical assessments (LIC 602) and reappraisal for residents #3, #4, and #5 to regina.cloyd@dss.ca.gov by January 19, 2024. Glenda will ensure that all dementia residents have an annual medical assessment and all clients in care will have an annual reappraisals or whenever there is a change in condition, whichever occurs first. Documents will be maintained in the resident's file.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/21/2023 03:53 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: INDIAN PEAK MANOR
FACILITY NUMBER: 198602210

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA did not observe that the administrator recertification requirements were met which poses a potential safety and personal rights risk to persons in care. LPA had the discussion with Glenda Marquez.
POC Due Date: 01/19/2024
Plan of Correction
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Glenda Marquez will submit RCFE Administrator Recertification application and submit proof of correction to regina.cloyd@dss.ca.gov by the POC due date. Administrator will ensure that recertification application is postmarked before the expiration due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


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: INDIAN PEAK MANOR
FACILITY NUMBER: 198602210
VISIT DATE: 12/21/2023
NARRATIVE
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5 staff records were reviewed, 5 out of 5 staff records had required criminal record clearances or criminal record exemptions. Two staff interviews were conducted.

5 resident records were reviewed and two residents’ medication was reviewed. Two residents were interviewed.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

During record review, LPA did not observe annual medical assessments and reappraisals for three residents diagnosed with dementia.

During record review, LPA did not observe that the Administrator’s recertification requirements were met.

An exit interview was conducted, plans of corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with Glenda Marquez.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6