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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320376
Report Date: 06/13/2023
Date Signed: 06/13/2023 02:26:09 PM

Document Has Been Signed on 06/13/2023 02:26 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:VILLA SOCORRO RPVFACILITY NUMBER:
198320376
ADMINISTRATOR:FULTON, PAULFACILITY TYPE:
740
ADDRESS:6320 TARRAGON RDTELEPHONE:
(310) 953-5518
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 0DATE:
06/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Paul Fulton, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPA) Ana Soto conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation.

An application was submitted to Community Care Licensing Department (CCLD) on 01/22/23 for an initial license for Residential Care For Elderly 60 years and above. The requested capacity is for (6) residents, (0) ambulatory, (5) non-ambulatory, (1) bedridden. Structure: Facility is a (5) bedroom, one (3) full bathroom and 1/2 bathroom, office area in kitchen, living room, dining room with mini bar/mini library, small family room, is a single story house with small front porch with small ramp, big back yard with covered porch with ramp, pool, and attached 2 car garage. The facility is a white stucco. Front yard landscape is in good condition. The back patio has umbrella, table and chairs. laundry are with washer/dryer. Signal System: Signal system in facility. Bedroom Residents: There shall be no more than two residents per bedrooms. 1 Bedroom is designated for shared bedrooms and 4 bedrooms are designated as private. Bedrooms are properly equipped with regulation guidelines of one bed, one chair, one night stand, one lamps and overhead lighting. Bedroom Staff: No room will be used for awake staff. Bathrooms: 1/2 bathroom located in the north side of facility next to the laundry area. 1st full bathroom is located in the hallway in the middle of all five bedrooms. 2nd full bathroom is inside bedroom #3, and 3rd bathroom is inside bedroom #5, all 3 1/2 bathrooms have working toilets and wash basins. Bathrooms also contain grab bars, folding bench, and non-skid mats, and trash cans with lids. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in hallway closets. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers and menu are posted and readily available for review in the entry hallway. Facility has a land line telephone located in the living room, phone is available for residents . 2 Fire extinguishers, one 4A60BC mounted in the kitchen, and the second 4A60BC is mounted on the wall next to the garage door which are labeled, they are tagged with current annual checks.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VILLA SOCORRO RPV
FACILITY NUMBER: 198320376
VISIT DATE: 06/13/2023
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Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in locked storage drawers in the kitchen cabinets. Adequate food supply is stored in kitchen, and consists of the following: 2 day perishables, and 7 week non-perishables. Smoke Detectors: There are 8 hard wired smoke detectors, and 1 battery operated carbon monoxide detector located in the laundry area which are operational. Appliances: Stove, dishwasher, microwave, and washer/dryer, refrigerator are in working condition. The residence is equipped with central air and heat. Toxins: Cleaning supplies, and toxins are stored in two location: locked cabinet under the kitchen island and in the kitchen cabinet below the sink. Water Temperature: Water was tested in bathrooms and kitchen sink within 110 degrees Fahrenheit. Medication, First-Aid Kit & Book: Designated area for centrally stored medication is located in the kitchen cabinet. First aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which is located in the kitchen cabinet with medications, it is locked and available for staff use. Resident & Staff Files: Designated area for files will be located in the kitchen cabinet with lock. Pools/Jacuzzi & Pets: There is a locked and gated pool. There are no pets on these premises. Fire Clearance: Fire clearance does indicate delayed egress and locked perimeter. Component III: Waived at the time of Pre-Licensing.

No corrections needed.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC809 (FAS) - (06/04)
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