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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320345
Report Date: 04/02/2025
Date Signed: 04/02/2025 04:27:11 PM

Document Has Been Signed on 04/02/2025 04:27 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:OCEAN VISTA RESIDENTIAL CAREFACILITY NUMBER:
198320345
ADMINISTRATOR/
DIRECTOR:		CHERYL CAMBAY RABOYFACILITY TYPE:
740
ADDRESS:2900 S. ANCHOVY AVENUETELEPHONE:
(424) 205-5014
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY: 6CENSUS: 5DATE:
04/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:11 AM
MET WITH:Cheryl CambayTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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On 04/02/2025, Licensing Program Manager (LPM) Ulysses Coronel, and Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced annual required visit using the CARE Inspection Tool. LPA Anguiano met with Cheryl Cambay and explained the purpose of today’s visit. The facility is licensed to Age range 60 and over. Approved for six (6) non-ambulatory residents, of which one (1) may be bedridden in bedroom #1. Hospice waiver approved for two (2) residents.


The facility consists of the following: LPM and LPA toured facility Kitchen, Dining Room, Living Room, (4) Bedrooms, (2 1/2) Bathrooms, Garage, Back Yard, and Patio with shaded area. LPM and LPA observed sufficient storage areas for kitchen supplies, linens, medications (secured) and chemicals (secured).

LPA Ulysses Coronel and Jose Anguiano toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit.

Bathrooms were operational. Hot water temperature measured at 121 to 126 degrees F between 3 bathrooms.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and 2 days supplies perishable, and 7 days non-perishable food was maintained.
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Jose Anguiano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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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Document Has Been Signed on 04/02/2025 04:27 PM - It Cannot Be Edited


Created By: Jose Anguiano On 04/02/2025 at 02:38 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: OCEAN VISTA RESIDENTIAL CARE
FACILITY NUMBER: 198320345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.317
Regulations
Every residential care facility for the elderly, as defined in Section 1569.2, shall, for the purpose of addressing issues that arise when a resident is missing from the facility, develop and comply with an absentee notification plan as part of the written record of the care the resident will receive in the facility, as described in Section 1569.80. The plan shall include and be limited to the following: a requirement that an administrator of the facility, or his or her designee, inform the resident’s authorized representative when that resident is missing from the facility and the circumstances in which an administrator of the facility, or his or her designee, shall notify local law enforcement when a resident is missing from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above, the licnsee did not develop an absentee notification plan that includes informing the resident’s authorized representative and notify local law enforcement when a resident is missing from the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2025
Plan of Correction
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The licensee agreed to develop an absentee notification plan. Proof of correction will be submitted to jose.anguiano@dss.ca.gov

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:
Jose Anguiano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2025


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: OCEAN VISTA RESIDENTIAL CARE
FACILITY NUMBER: 198320345
VISIT DATE: 04/02/2025
NARRATIVE
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Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. All mandated inspection control posters were posted including Activities Calendar and Food Menu.

LPA conducted an audit of 5 resident records, and 4 personnel records. The facility is current in CCLD annual license fees. The administrator certificate is valid. The facility has a Liability Insurance Certificate valid through 03/06/2026.

The following were observed during today’s visit : Hot water temperature measured at 121 to 126 degrees F between 3 bathrooms. Resident #4 who is bedridden is using bedroom #3 per facility's fire clearance only bedroom#1 is allowed to have bedridden residents.

Deficiencies have been observed and citation were issued (ref. LIC 809-D). Civil Penalties are being assessed please see LIC421IM.

An exit interview conducted, and plans of corrections were developed with Cheryl Cambay Raboy. A copy of the report and appeals rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Jose Anguiano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/02/2025 04:27 PM - It Cannot Be Edited


Created By: Jose Anguiano On 04/02/2025 at 03:22 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: OCEAN VISTA RESIDENTIAL CARE
FACILITY NUMBER: 198320345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenace and Operation. Water supplies and plumbing fixtures shall be maintained as follows. Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews the licensee did not comply with the section cited above: The hot water temperature in Bathrooms 1,2 and 3 tested between 121-126 F which poses/posed an immidiate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2025
Plan of Correction
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The Administrator adjusted the water temperature to 110 F during the visit. The licensee agreed to create a plan to ensure compliance with Title 22 87303(e)(2) Maintenance and Operation. Proof of correction will be submitted to jose.anguiano@dss.ca.gov by the POC due date.
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearence. All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
(2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews and record reviews, the licensee did not comply with the section cited above, resident #4 who is bedridden is using bedroom #3, per facility's fire clearance only bedroom#1 is allowed to have bedridden residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2025
Plan of Correction
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Licensee agreed to create a plan ensuring compliance with Title 22 87202(a)(2) Regulation Fire Clearence. Proof of correction will be submitted to jose.anguiano@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.
Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:
Jose Anguiano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2025


LIC809 (FAS) - (06/04)
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