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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320376
Report Date: 06/14/2024
Date Signed: 06/14/2024 11:08:58 AM

Document Has Been Signed on 06/14/2024 11:08 AM - 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:VILLA SOCORRO RPVFACILITY NUMBER:
198320376
ADMINISTRATOR/
DIRECTOR:		ATENCIO, CHRISTINAFACILITY TYPE:
740
ADDRESS:6320 TARRAGON RDTELEPHONE:
(310) 953-5518
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 6DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Christina Atencio/AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:08 AM
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On 6/14/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Christina Atencio /Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) elderly adults ages 60 and above, of which (1) can be bedridden on room #1 and (6) can be non-ambulatory. The facility has an approved hospice waiver for (6).

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.



LPA Iniguez and the facility staff toured the physical plant. Pool was securely locked and gated . LPA inspected a total of (5) bedrooms and (3) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 113°F to 115°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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: VILLA SOCORRO RPV
FACILITY NUMBER: 198320376
VISIT DATE: 06/14/2024
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During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 4/18/24.

A review of (3) residents' service files and (3) staff personnel files was maintained in order. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies; therefore, no citations were issued at this time.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Christina Atencio / Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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