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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608244
Report Date: 10/14/2021
Date Signed: 10/14/2021 06:57:56 PM

Document Has Been Signed on 10/14/2021 06:57 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:ROYAL PALMS VILLAFACILITY NUMBER:
197608244
ADMINISTRATOR:MARIVI PITTSFACILITY TYPE:
740
ADDRESS:17419 ELGAR AVENUETELEPHONE:
(310) 817-4298
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6CENSUS: 1DATE:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Ja Feliciano/Marivi Pitts - AdministratorTIME COMPLETED:
03:00 PM
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On 10/14/2021, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Administrator Marivi Pitts and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly residents ages 60 and above of which five (5) can be non-ambulatory and one (1) can be bedridden. The facility is approved for two (2) hospice.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident's rooms, two (2) bathrooms, two (2) living area, dining area, kitchen, staff storage room and laundry area next to kitchen and outside covered patio area.

Currently, one (1) of the resident’s room are being occupied by staff (room #6). One (1) client was on the premises at the time of the visit.

LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 108.6 F to 119.8 F in the kitchen and bathrooms. A comfortable temperature of 74 degrees was maintained in the facility.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ROYAL PALMS VILLA
FACILITY NUMBER: 197608244
VISIT DATE: 10/14/2021
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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Two (2) fire extinguishers were fully charged in the kitchen area and living room area. Smoke detectors and carbon monoxide were operable. A review of Medication Administration Records (MAR) was maintained in order and accurate.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff and residents were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

Advisory Notes – One (1) Technical Assistance were issued, please see LIC9102-AN.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Marivi Pitts.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC809 (FAS) - (06/04)
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