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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320376
Report Date: 05/29/2025
Date Signed: 05/29/2025 03:08:36 PM

Document Has Been Signed on 05/29/2025 03:08 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:VILLA SOCORRO RPVFACILITY NUMBER:
198320376
ADMINISTRATOR/
DIRECTOR:		ATENCIO, CHRISTINAFACILITY TYPE:
740
ADDRESS:6320 TARRAGON RDTELEPHONE:
3109535518
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 6DATE:
05/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:33 AM
MET WITH:Christina Atencio, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:04 PM
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On 05/29/25 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA was met by staff one, Christina Atencio Administrator (S1) and LPA verified S1 Administrator Certificate #7035385740 is valid through 11/13/26, and the purpose of the visit was explained. The facility is licensed to serve (6) elderly adults ages 60 and above, of which (1) may be bedridden in room number one (#1). Six residents (6) may be non-ambulatory and the facility has an approved hospice waiver for six (6) residents.
The facility is a single-story home, located in a residential neighborhood, which includes five (5) bedrooms, three (3) full bathrooms for resident use and one (1) 1/2 (0.5) bathroom designated for staff use, office area in kitchen, living room, dining room with mini bar/mini library, small family room. Facility has a shaded front porch, equipped with a ramp to relocate non-ambulatory residents, a back yard with a shaded porch, also with ramp for residents to access the back yard, one (1) gated pool, and an attached 2 car garage.
LPA and S1 toured the physical plant, inside & out. Pool was checked and LPA confirmed the water is securely locked and gated, within Title 22 regulations. 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 checked and there was no mold or mildew present, water temperature ranged up to 116.2°F and were within Title 22 regulations. Smoke and carbon monoxide detectors were in operable condition. The facility's indoor temperature was measured at a comfortable 76°F.

Report continues, see LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2025
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: VILLA SOCORRO RPV
FACILITY NUMBER: 198320376
VISIT DATE: 05/29/2025
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During today's visit, LPA 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 inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, all of which was adequately stored. All fire extinguishers were charged and operable, most recently purchased on 07/24/24. The last Fire/Earthquake Drill was conducted on 04/09/25. A review of six (6) residents' service files and three (3) staff personnel files were reviewed and in order. LPA reviewed two (2) Medication Administration Records (MARs) and found no discrepancies. Facility Liability insurance is active, set to expire on 08/25/25.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies during today's visit. There have been zero (0) deficiencies cited during today's visit.

An exit interview was conducted with staff one, Christina Atencio Administrator (S1), and a copy of this report has been provided.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC809 (FAS) - (06/04)
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