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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205367
Report Date: 08/27/2025
Date Signed: 08/29/2025 10:15:45 AM

Document Has Been Signed on 08/29/2025 10:15 AM - 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:WESTCHESTER VILLAFACILITY NUMBER:
198205367
ADMINISTRATOR/
DIRECTOR:		EVANGELINE AGATEPFACILITY TYPE:
740
ADDRESS:220 W. MANCHESTER BLVD.TELEPHONE:
(310) 673-1093
CITY:INGLEWOODSTATE: CAZIP CODE:
90301
CAPACITY: 174CENSUS: 84DATE:
08/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Maria MascardoTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Required - 1 Year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the evaluation, the facility is clear of COVID-19 infection.

LPA Bunker met with Administrator Maria Mascardo and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan and Infection Control Report. There are currently 84 residents and in placement. LPA Bunker verified the current staff fingerprints that were cleared and associated with the facility. The facility's annual fees are up to date. The facility has a Dementia Program. The facility is licensed for three hospice care residents. The facility has sufficient staff available and competent to provide the services necessary to meet resident needs.

The following 12 Domains will be observed and reviewed: Infection Control, Operational Requirements, Physical Plant & Environmental Safety, Staffing, Personnel Records-Staff Training, Residents Rights-Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records-Incident Reports, Disaster Preparedness, and Residents with Special Health Needs. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

See continued LIC809-C page 2
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WESTCHESTER VILLA
FACILITY NUMBER: 198205367
VISIT DATE: 08/27/2025
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Continued LIC809-C page 2

The above facility is a two-story commercial building. Administrator Ms. Mascardo, LPA Bunker toured the facility which consisted of the following: The first-floor Lobby/receptionist area, business office/copy area, medication room, Administrator's office, record office, 24 bedrooms and bathrooms, emergency supply room, storage rooms, 3 living rooms, 2 dining rooms, kitchen, resident's private laundry room, commercial laundry room, activity room, recreation/activity director's office, men and women public restrooms, 2 employee's lounges, men and women employee's restrooms, beauty salon, linen room, housekeeping supply room, patios, shaded area, indoor/outdoor activity area, and gated security parking lot.

The Memory Care Unit (MCU) has 8 bedrooms and bathrooms, a living room/dining room, an Activity/TV area, and men's and women's public restrooms.

The second floor consisted of 52 resident bedrooms and bathrooms, a Doctor's office, a Home Health agency office, men's and women's public restrooms, men's and women's employees' restrooms, a resident's private coin laundry room, TV room, library/living room, game room, storage rooms, and storage closets, and an upstairs patio area.

Administrator Ms. Mascardo and LPA Bunker observed 25 residents' bedrooms that had the required furniture: a bed, one chair, a nightstand, adequate lighting, a closet, and drawer space. There was ample space to accommodate each resident comfortably. Documents are posted as mandated. Bedrooms contain the required furniture, and Bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, and comfort, including grab bars and non-slip surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. See continued LIC809-C page 3
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: WESTCHESTER VILLA
FACILITY NUMBER: 198205367
VISIT DATE: 08/27/2025
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Continued LIC809-C page 3

LPA Bunker observed the facility’s infection control practices, screening protocols for residents and visitors, sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of Personal Protective Equipment (PPE) was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed.

Medications are locked, and records are current. Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and being clear of any potential hazards to the residents. The first aid kit is fully stocked with a manual, smoke detectors, sprinklers, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 115.3 on the first floor and 119.1 degrees Fahrenheit on the second floor, fire extinguishers are fully charged, adequate linen supply, the residents' emergency call light is operable, the facility telephones are in working condition, resident's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were properly covered.

The last Fire/Emergency Drill was conducted on 07/07/2025.

Staff were given training on the dependent adult and elder abuse reporting video.

There were no deficiencies cited.

Exit interview conducted.
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4