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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320118
Report Date: 12/04/2025
Date Signed: 12/04/2025 11:51:39 AM

Document Has Been Signed on 12/04/2025 11:51 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, 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: 5DATE:
12/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Ruby VidadTIME VISIT/
INSPECTION COMPLETED:
11:51 AM
NARRATIVE
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On 12/04/25 Licensing Program Analyst (LPA) Villegas conducted an unannounced required annual visit using the CARE Inspection Tools. LPA met with staff Ruby Vidad as the purpose of the visit was explained. The facility is licensed for (6) 60-year-old or older non-ambulatory adult residents; 2 may be bedridden in bedroom #2. There is an approved hospice waiver for 6. Facility fees are current, liability insurance active (09/24/26).

The facility is a one story home that consists of (4) resident bedrooms, (3) resident bathrooms, living room, dining room, kitchen, pantry room, office area, attached garage with washer and dryer/ storage area, and a backyard with table and chairs. 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. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to residents, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 4 staff records, 3 client records, and 3 medication administration records. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 09/12/25, 1 fire extinguisher fully charged, carbon monoxide and smoke detectors are interconnected and operational.

Exit interview conducted, appeal rights explained, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Lizeth Villegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2025
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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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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Document Has Been Signed on 12/04/2025 11:51 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 12/04/2025 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PRIME VILLA CLOUD
FACILITY NUMBER: 198320118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)

87458 Medical Assessment
The medical assessment shall include, but not be limited to:
A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: Communicable tuberculosis.

Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above As residents #1-3 (R1-R3) did not have a TB test in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2025
Plan of Correction
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Licensee will ensure all residents in care and/or future residents have a TB test with results on file, TB test results shall be signed by a licensed physician. Licensee to send LPA Villegas proof of TB test for residents #1-3 by POC due date.
Type B
Section Cited
CCR
87465(a)(1)

87465 Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

Deficient Practice Statement
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Based on [(observation) (record review)], the licensee did not comply with the section cited above as LPA did not observe any records or documentation indicating that Residents #R1-R3 have seen a dentist of medical specialist in 2025 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2025
Plan of Correction
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Licensee to obtain copies of medical and dental visits for 2025 and ensure they are placed in resident files moving forward. LPA to obtain proof that residents have had medical and dental visits for 2025 by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2025


LIC809 (FAS) - (06/04)
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