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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320051
Report Date: 11/17/2022
Date Signed: 11/17/2022 03:27:25 PM

Document Has Been Signed on 11/17/2022 03:27 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PEPPER TREE ASSISTED LIVINGFACILITY NUMBER:
198320051
ADMINISTRATOR:KLEIN, STEPHANIEFACILITY TYPE:
740
ADDRESS:2353 251ST STREETTELEPHONE:
(424) 250-9786
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 6CENSUS: 6DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:caregiver - Miguel Can/Licensee Stephanie KleinTIME COMPLETED:
03:30 PM
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On 11/17/2022, 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 caregiver Miguel Can and was later joined by Licensee Stephanie Klein and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly residents ages 60 and above. The facility is approved for six (6) non-ambulatory residents of which and may retain four (4) hospice.


The facility is a single-story structure located in a residential neighborhood. The facility consists of the following: five (5) resident's rooms, four (4) bathrooms, a living room area, dining area and kitchen. There is a detached garage located next to the facility used for a staff break room and for storage only. The washer and dryer are located in the garage. There is a patio area in front of the garage with shade and ample seating. There is also a patio area in the backyard with shade and ample seating for the residents.


LPA and caregiver toured the physical plant. There are 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 met Title 22 requirements in the kitchen and bathrooms and measured between 106.0 F and 110.5 F. A comfortable temperature was maintained in the facility.


Evaluation Report Continues on LIC 809-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PEPPER TREE ASSISTED LIVING
FACILITY NUMBER: 198320051
VISIT DATE: 11/17/2022
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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 and toxins were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. There was one (1) fire extinguisher fully charged located in the kitchen area. First aid kit was available in the pantry area. Smoke alarms and carbon monoxide detectors 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 six (6) residents, one (1) staff and private caregivers present during the tour. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE) with most of the PPE located in the garage. All mandated inspection control posters were posted.

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

There were no deficiencies cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Licensee Stephanie Klein.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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