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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320305
Report Date: 11/02/2024
Date Signed: 11/02/2024 01:21:56 PM

Document Has Been Signed on 11/02/2024 01:21 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:
11/02/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:57 AM
MET WITH:Tri KristianingsihTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 11/02/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced annual continuation inspection and met with Staff Tri Kristianingsih. LPA explained the purpose of the visit and spoke with the Administrator Ma Salvacion Medina over the phone.

The purpose of today's visit is to deliver deficiencies observed on 10/12/2024. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8 (See LIC809-D pages).

On 10/12/24, LPA did not observe a operable washer and dryer. Administrator stated that it has been out since 10/11/24.



On 10/12/24, LPA observed an outdoor medical equipment and grill blocking one resident outdoor exit. LPA also observed a resident's couch blocking another resident's outdoor exit. LPA observed material (buckets, bags, rug, equipment, laundry baskets, trash cans, and etc) around the perimeter of the house.

Continue to LIC809-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 11/02/2024 01:21 PM - It Cannot Be Edited


Created By: Regina Cloyd On 11/02/2024 at 12:15 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: 11/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87413(a)(1)
Personnel - Operations
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

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 which poses a potential safety risk to persons in care. On 10/12/2024, Administrator was not present and staff had a challenging time locating facility records, resident records, and staff records. Also, during record and medication review, Resident #2 needed two staff members. Two residents remained in the living room and the tv program was turned off for about 60 - 90 minutes.
POC Due Date: 11/12/2024
Plan of Correction
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The Administrator will provide a plan of correction to regina.cloyd@dss.ca.gov by the POC due date.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 which poses a potential health and safety risk to persons in care. On 10/12/2024, LPA observed a pill box sorter in the medication cabinet for Resident #2.
POC Due Date: 11/12/2024
Plan of Correction
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The Administrator will provide a plan 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: 11/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/02/2024 01:21 PM - It Cannot Be Edited


Created By: Regina Cloyd On 11/02/2024 at 12:15 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: 11/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above which posed a potential health and personal rights risk to persons in care. On 10/12/2024 1:16 PM, LPA smelled feces in the facility until LPA's 5:00 PM departure.
POC Due Date: 11/12/2024
Plan of Correction
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The Administrator will send a plan of correction to regina.cloyd@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2024


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: 11/02/2024
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On 10/12/2024, the Administrator was not present and staff had a challenging time locating facility records, resident records, and staff records. LPA and staff had to communicate with Administrator over the phone and still faced challenges. Also, during record and medication review, Resident #2 needed two staff members. Two residents remained unsupervised in the living room and the tv program was turned off for about 60 - 90 minutes.

On 10/12/2024, LPA observed a pill box sorter in the medication cabinet for Resident #2.

On 10/12/2024 1:16 PM, LPA smelled feces in the facility until LPA's 5:00 PM departure.

An exit interview was conducted, technical assistance provided, plans of correction developed, and a copy of this report with appeal rights was discussed with the Administrator Ma Salvacion Medina over the phone. Hard copies were provided to Staff Tri Kristianingsih.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC809 (FAS) - (06/04)
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