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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320306
Report Date: 08/20/2025
Date Signed: 08/20/2025 03:30:11 PM

Document Has Been Signed on 08/20/2025 03:30 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:
08/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:42 PM
MET WITH:Rose MatuteTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On August 20, 2024, Licensing Program Analyst (LPA) Deborah Lee 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).

Structure

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.

Physical Plant

LPA and Licensee toured the facility inside and outside. LPA observed that there were no bodies of water on the premises. 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.

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NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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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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: 08/20/2025
NARRATIVE
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Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational. A comfortable temperature of 75 degrees F. was maintained in the facility

Bedrooms LPA inspected all 5 bedrooms. All bedrooms were observed to have the required furniture including beds, dressers, nightstands with lamps, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting.

Bathrooms LPA inspected the facility bathrooms. In the resident’s bathroom the toilet, faucets, and shower were fully operational. All safety handrails were securely fastened. LPA observed the showers to be clean and free of mold or mildew. The shower had a nonskid material in bottom and shower chair. Resident’s toiletries are secured in a cabinet under the sink. The water temperature measured 111.7-degrees Fahrenheit. The Staff bathroom was observed to be clean. The toilet and faucets are operational. Both bathrooms were observed to be clean, in good repair and within Title 22 regulations.

Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens, towels, and blankets in the hall closets. LPA observed incontinence care products stored in the resident’s closets and in the hall closet.

Kitchen

LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, dishwasher, washer, dryer, refrigerator, and additional freezer. LPA observed an ample supply of cutleries, pots, pans, and bowls to be in good repair. LPA observed knives and additional sharps to be secured in locked drawers in the kitchen and are inaccessible to residents.

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NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 08/20/2025
NARRATIVE
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LPA observed a 2-day supply of perishable foods and a 7-day supply of nonperishable foods. All food was properly stored and labeled. Cleaning products and toxins were secured in a locked in a closet in the laundry room inaccessible to residents.

Common Rooms In the living room, LPA observed, ample seating for all residents. In the dining room, LPA observed a 6 seated rectangle table and chairs to accommodate all residents. LPA observed all walkways and hallways to be clear, clean, and free of obstructions and hazards. LPA observed ample lighting is all rooms. The facility is maintained at a comfortable temperature.

Safety LPA observed and tested smoke/carbon monoxide detectors to be fully operable. LPA observed 2 fully charged fire extinguisher mounted on the wall, last serviced on 11/6/24. The last emergency drill was conducted on 4/15/25. LPA inspected the First Aid kit and found it contained an ample supply of required items and a manual. LPA observed the required posting in the facility. LPA observed all exits to be clear and easily accessible.

Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked cabinet in the kitchen area.

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NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 08/20/2025
NARRATIVE
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Files LPA reviewed 5 resident files and found 5 out of 5 contained all the necessary documentation. LPA reviewed 3 staff files and found 3 out of 3 contained the required documentation, certification, and training. Liability Insurance, Liability Insurance expiration date 9/20/25.

Infection Control During the visit, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with PPE supplies are readily available to staff, and an additional 30-day supply of PPE was observed. Sufficient paper towels, cleaning, and disinfecting supplies were observed. LPA observed required postings throughout the facility.

LPA did not observe any deficiencies during the time of visit.

An exit interview was conducted with Rose Matute, Licensee and a copy of this report was provided.

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NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5