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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320306
Report Date: 08/22/2024
Date Signed: 08/22/2024 03:59:11 PM

Document Has Been Signed on 08/22/2024 03:59 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:MARCOSA'S VILLAFACILITY NUMBER:
198320306
ADMINISTRATOR/
DIRECTOR:		FIGUEROA, JUN FAUSTO D.FACILITY TYPE:
740
ADDRESS:1024 E. FREELAND STREETTELEPHONE:
(562) 428-0033
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 6CENSUS: 6DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:36 PM
MET WITH:Rosita Matute, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On August 22, 2024, Licensing Program Analyst (LPA) Deborah Lee and Licensing Program Manager Eva Alvarez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Licensee Rose Matute and explained the purpose of today’s visit. LPA was granted entry to this facility. The facility is licensed to operate for six (6) non-ambulatory elderly residents ages 60 and over. The facility has a hospice waiver approved for six (6).

This facility is a single-story residence located in a residential neighborhood. The home consists of five (5) bedrooms, four (4) bathrooms, kitchen, living room, laundry area and a dining room. The home has a detached garage and an outside shaded sitting area.

LPA toured the physical plant with Licensee Rose Matute. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. The bathrooms were found to be within Title 22 regulation. Water temperature properly measured 110 degrees F. A comfortable temperature was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene were stored and not accessible to residents. The kitchen was inspected and there is sufficient supply of perishable and non-perishable food available and maintained properly. Two fire extinguishers were fully charged. Smoke detectors and carbon monoxide were tested and operable. First aid kit was checked an in order with manual. Toxins and sharps were locked and inaccessible to clients. Outside grounds were toured and no bodies of water were observed. Shaded patio furniture was accessible. Exits and walkways around the home were free of debris and hazards. Facility has a working telephone landline. A review of Medication Administration Records and Fire Drill are maintained and in order. The last fire drill was conducted on 8/2/2024.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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: MARCOSA'S VILLA
FACILITY NUMBER: 198320306
VISIT DATE: 08/22/2024
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Due to time constraints LPA was unable to complete this annual visit and willreturn in the near future.
No citation was issued today and copy of this report was provided to the licensee Rosita Matute.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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