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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320277
Report Date: 06/19/2024
Date Signed: 06/19/2024 12:46:46 PM

Document Has Been Signed on 06/19/2024 12:46 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:LEGACY VILLA SENIOR CAREFACILITY NUMBER:
198320277
ADMINISTRATOR/
DIRECTOR:		CLARKE, STEPHENFACILITY TYPE:
740
ADDRESS:21012 DOBLE AVENUETELEPHONE:
(310) 418-7938
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY: 6CENSUS: 6DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:47 AM
MET WITH:Joel MoralesTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 06/19/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced visit to the facility listed above. LPA met with Administrator, Joel Morales, and the purpose of today’s visit was explained. The facility is licensed for six (6) adults aged 60 and above. They have a hospice waiver for six (6). During time of visit all six (6) residents were present

Physical Plant/Structure The facility is a single-story home in a residential neighborhood. The facility consists of five (5) bedrooms, three (3) bathrooms, two (2) car garage, living room, family room, dining room, kitchen, laundry area, and a shaded patio. LPA observed a table, chairs, and couch under the shaded patio. LPA observed all walkways around the home to be clean, clear, and free of obstructions, debris, and hazards. LPA did not observe any bodies of water on the premises.

Bedrooms LPA inspected all bedrooms and observed the walls and floors to be clean and in good repair. All rooms had the required furniture including a bed, dresser, nightstand, chair, and storage space for personal belongings. LPA observed beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed bed linens to be in good repair. An ample supply of bed linens was observed in the hall cabinet.


Continued on LIC809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LEGACY VILLA SENIOR CARE
FACILITY NUMBER: 198320277
VISIT DATE: 06/19/2024
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Bathrooms LPA inspected the facility bathrooms and found them to be within Title 22 regulations. All bathrooms were observed clean and operational. LPA observed storage area for personal hygiene products. LPA observed an ample supply of towels and personal hygiene products available for residents. All showers had a nonskid mat, shower chair, and secured safety handrails. The water temperature measured between 111.2 and 113.6-degrees Fahrenheit.
Kitchen LPA inspected the facility kitchen and found it to be clean and sanitary. LPA observed all appliances to be operational and in good repair. LPA observed an ample supply of dishware, cookware, and cutleries in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods, properly stored and labeled. LPA observed knives and other sharps secured in a locked drawer and are inaccessible to residents. Cleaning supplies are secured in a locked cabinet in the laundry area and are inaccessible to residents. The water temperature measured 111.5-degrees Fahrenheit.
Common Rooms In the living room, LPA observed a couch and two (2) chairs to accommodate residents. In the family room, LPA observed 7 recliners to accommodate residents. LPA observed games and reading material available to residents. LPA observed a fireplace that was properly screened. The dining room has a large table and chairs to accommodate all residents. LPA observed all walkways and hallways in the home to be clean, clear, and free of obstructions and hazards. All rooms have ample lighting. The facility was maintained at a comfortable temperature.

Continued on LIC809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LEGACY VILLA SENIOR CARE
FACILITY NUMBER: 198320277
VISIT DATE: 06/19/2024
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Safety LPA observed multiple fully charged fire extinguisher in the facility, last serviced on 05/01/23. All smoke and carbon monoxide detectors are operable. The last emergency drill was conducted on 05/06/24. LPA inspected the First Aide Kit and observed it had the required items and a manual. All exits are marked with an EXIT sign. The facility’s Emergency and Disaster Plan is posted in the family room. LPA observed all required documents posted in the facility. The facility has a working landline telephone. There are no firearms are ammunition stored at the facility.
Files/ Interviews LPA reviewed the files for the six (6) residents and observed they had the required documents. LPA spoke with six (6) residents, and all were happy with the care they receive at the facility. LPA reviewed the administrator and two (2) staff files and found they contained the required documents, certification, and training. The administrator’s Administrator Certificate is valid till 09/08/24. LPA spoke with two (2) staff, and all were able to answer questions regarding policy, procedure, and resident care and personal rights. LPA received and reviewed the facility Liability Insurance which is valid till 01/08/25.
Medication LPA observed all Centrally Stored Medications secured in a locked cabinet in the kitchen, and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the medications and Medication Administration Record (MAR) for the six (6) residents. Six (6) out of six (6) resident’s MARs and medication are consistent with properly documented records.


Continued on LIC809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LEGACY VILLA SENIOR CARE
FACILITY NUMBER: 198320277
VISIT DATE: 06/19/2024
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Infection Control Upon entry, LPA observed a sanitizing station and visitor sign-in log. LPA observed on the table there is hand sanitizer and masks available. LPA observed all required Infection Control signs posted in the facility. LPA observed a 30-day supply of Personal Protective Equipment (PPE).

During today’s visit, LPA did not observe or cite any deficiencies.

An exit interview was conducted with Administrator, Joel Morales, and a copy of this report was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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