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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608379
Report Date: 01/10/2025
Date Signed: 01/10/2025 02:46:41 PM

Document Has Been Signed on 01/10/2025 02:46 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:AVENIDA VILLA, INC.FACILITY NUMBER:
197608379
ADMINISTRATOR/
DIRECTOR:
PHILLIP ROMEROFACILITY TYPE:
740
ADDRESS:1803 AVENIDA FELICIANOTELEPHONE:
(310) 930-6455
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 6DATE:
01/10/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:May Drapeam, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:11 PM
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On 01/10/25 The Department of Social Services, Community Care Licensing Division (CCLD) staff conducted a case management visit to complete the facilities' annual visit which was held as follows:

On 01/10/25 CCLD conducted a subsequent annual visit, which was held as follows: CCLD staff was met by May Drapeau, Administrator (S1), and the purpose of the visit was explained. The current census of the facility is six (6) residents. CCLD conducted a records review of five (5) staff records, six (6) resident records, and two (2) residents' medication administration record (MAR). No discrepancies were observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting was provided, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature was properly measured at 111.2°F in bathroom #1, 111.3°F in the kitchen and 109.3°F in bathroom #2, all within title 22 water temperature regulation. The last fire drill was conducted 12/15/24.

On 11/26/24 CCLD conducted an initial annual visit which consisted of the following:


CCLD staff was met by May Drapeau, Administrator (S1), and the purpose of the visit was explained. The facility is licensed for six residents, age 60 and over, of which five (5) may be non-ambulatory residents, along with one (1) bedridden resident. The facility has been approved for (2) hospice waivers and are compliant under California code of regulation 87705 – Care of persons with Dementia. The current census is five (5) residents. Facility fees are up to date and liability insurance is active with an expiration date of 07/16/25.

Report continues, see LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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 2
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: AVENIDA VILLA, INC.
FACILITY NUMBER: 197608379
VISIT DATE: 01/10/2025
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The facility is a single-story structure located in a residential neighborhood and consists of the following: (5) resident bedrooms, (2.5) resident bathrooms, living room, dining room, kitchen, staff room, office area, attached garage which contains a washer and dryer / storage area and an extra refrigerator. The facility also has a front and back yard, equipped with a shaded area with table and chairs. There are no weapons/ammunition stored on the premises and there are no bodies of water on-site. A supply of seven (7) day perishable and two (2) days non-perishable food was observed. Emergency Water supply is located in the garage. Toxins and knifes were observed to be stored and inaccessible to clients in care. Last fire drill was on 07/26/24. Carbon monoxide and smoke detectors were observed and are operational, a landline and internet were observed in working condition. The facility's (2) Fire Extinguishers were checked and found to be fully charged, maintained annually as of 06/27/24. All exits and walkways are free of debris/hazards.

An exit interview was held with May Drapeau (S1) and a copy of this report was provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC809 (FAS) - (06/04)
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