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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320305
Report Date: 10/12/2024
Date Signed: 10/12/2024 05:02:19 PM

Document Has Been Signed on 10/12/2024 05:02 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:PALOS VERDES CARE COTTAGEFACILITY NUMBER:
198320305
ADMINISTRATOR/
DIRECTOR:		MEDINA, MA. SALVACIONFACILITY TYPE:
740
ADDRESS:1808 PENINSULA VERDE DR.TELEPHONE:
(562) 356-7130
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 4DATE:
10/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:11 PM
MET WITH:Robert LimTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 10/12/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff Robert Lim. LPA spoke with the Administrator Ma Salvacion Medina over the phone.

The facility is licensed to serve six (6) ambulatory residents, all of which four (4) may be non-ambulatory and one (1) may be bedridden. Bedroom #1 is approved for ambulatory. Bedroom #2 and #4 are approved for non-ambulatory. Bedroom #3 is approved for bedridden and non-ambulatory. The facility has a hospice waiver approved for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It has a ramp that goes along the west side of the facility. It consists of (4) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room and a attached garage.



Staff accompanied LPA inside and outside the facility during this inspection.

Resident bedrooms had the required furniture, bed linens, and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew, and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2024
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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Document Has Been Signed on 10/12/2024 05:02 PM - It Cannot Be Edited


Created By: Regina Cloyd On 10/12/2024 at 04:31 PM
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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALOS VERDES CARE COTTAGE
FACILITY NUMBER: 198320305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(g)(1)
87303 Maintenance and Operation (g) Facilities which have machines and do their own laundry shall: (1) Have adequate supplies available and equipment maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above for the washer and dryer which poses/posed a potential health risk to persons in care. LPA did not observe a operable washer and dryer. Administrator stated that it has been since 10/11/24.
POC Due Date: 10/22/2024
Plan of Correction
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The Administrator will send evidence of proof of correction to regina.cloyd@dss.ca.gov by the POC Due Date.
Type B
Section Cited
CCR
87307(d)(6)
87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for two bedroom exits and outdoor perimeter which poses/posed a potential safety risk to persons in care. LPA observed oudoor medical equipment and grill blocking one resident outdoor exit. LPA observer a resident's couch blocking resident's outdoor exit. LPA observe material around the perimeter of the house.
POC Due Date: 10/22/2024
Plan of Correction
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The Administrator will email evidence of correction to regina.cloyd@dss.ca.gov by the 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.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2024


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: PALOS VERDES CARE COTTAGE
FACILITY NUMBER: 198320305
VISIT DATE: 10/12/2024
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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. Staff tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

Three (3) staff records were reviewed.

Four resident records were reviewed and two residents’ medication was reviewed.

Deficiencies were observed during today’s visit but due to insufficient time, an annual continuation is required.

An exit interview was conducted and a copy of this report was discussed with the Administrator over the phone and left with Staff Robert Lim.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024
LIC809 (FAS) - (06/04)
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