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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320118
Report Date: 10/25/2024
Date Signed: 10/25/2024 01:13:45 PM

Document Has Been Signed on 10/25/2024 01:13 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:PRIME VILLA CLOUDFACILITY NUMBER:
198320118
ADMINISTRATOR/
DIRECTOR:		ATENCIO, JOHN PAULFACILITY TYPE:
740
ADDRESS:1009 E MARCELLUS STTELEPHONE:
(562) 473-0620
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 6CENSUS: 6DATE:
10/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:42 AM
MET WITH:Efrelyn AtencioTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On October 25, 2024, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced required annual visit using the CARE Inspection Tools. LPAs met with staff Jennifer Cortez and explained the purpose of this visit. The Licensee back up administrator Efrelyn Atencio subsequently arrived to assist with the visit. The facility is licensed for (6) 60-year-old or older non-ambulatory adult clients; 2 may be bedridden. Currently, there are (6) non-ambulatory residents residing in the facility.

Structure The facility is a one story residential home consists of (4) resident bedrooms, (3) resident bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises.

Physical Plant LPA and facility staff Jennifer Cortez toured the facility inside and outside. LPA observed There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. LPA observed that facility had required postings: Facility license, personal rights, ombudsman information poster, facility sketch, exit signs, infectious disease postings,menu, and nutrition information.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PRIME VILLA CLOUD
FACILITY NUMBER: 198320118
VISIT DATE: 10/25/2024
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Bedrooms LPA inspected all (4) bedrooms--2 shared, and 2 private. All bedrooms were observed to have the required furniture including beds, dressers, night stands with lamps, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting.

Bathrooms LPA inspected the facility bathrooms. In the resident’s bathroom the toilet, faucets, and shower were fully operational. All safety handrails were securely fastened. LPA observed the showers to be clean and free of mold or mildew. The shower had a nonskid material in bottom and shower chair. Resident’s toiletries are secured in hall closet, and incontinent supplied store in resident's closet. The water temperature measured 110.2 degrees Fahrenheit. The toilet and faucets are operational. All bathrooms were observed to be clean, in good repair and within Title 22 regulations.

Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens, towels, and blankets in hall closet.

Kitchen LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, dishwasher, washer, dryer, refrigerator, and additional freezer. LPA observed an ample supply of cutlery, pots, pans, and bowls to be in good repair. LPA observed knives and additional sharps to be secured in locked drawers in the kitchen and are inaccessible to residents. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. The washer and dryer are located in detached garage.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PRIME VILLA CLOUD
FACILITY NUMBER: 198320118
VISIT DATE: 10/25/2024
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Common Rooms In the living room, LPA observed 4 recliners and a mounted TV. The dinning area dining contained a 4 seated dinning table, a ceiling fan and an area with hand sanitizer.

Safety LPA observed and tested smoke detectors (6) and (3) carbon monoxide detectors to be fully operable. LPA observed ( 1 ) fully charged fire extinguisher mounted on the wall in kitchen area. The last emergency drill was conducted on 8/3/2024 LPA inspected the First Aid kit and found it contained an ample supply of required items: Scissors, tweezers, guaze, disinfectant wipes, band aids. LPA observed all exits to be clear and easily accessible. All toxins locked.

Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked closet that is inaccessible to Residents in care.

Files LPA reviewed ( 6 ) resident files and found the contained all the necessary documentation. LPA reviewed (4) staff files and found they contained the required documentation, certification, and training.

Infection Control During the visit, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff.

There were no deficiencies cited during today’s visit.

An exit interview was conducted with Efrelyn Atencio, back up administrator and a copy of this report was provided.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
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