<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320397
Report Date: 12/05/2024
Date Signed: 12/05/2024 03:16:46 PM

Document Has Been Signed on 12/05/2024 03:16 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:DIVINE LIFE GUEST HOMEFACILITY NUMBER:
198320397
ADMINISTRATOR/
DIRECTOR:		ROSALDO, RODRIGOFACILITY TYPE:
740
ADDRESS:1711 W. 243RD ST.TELEPHONE:
(310) 310-1851
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 6CENSUS: 4DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:23 AM
MET WITH:Rodrigo RosaldoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On December 5, 2024, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced required annual visit using the CARE Inspection Tools. LPAs met with staff Alvin Geniza and explained the purpose of this visit. Rodrigo Rosaldo subsequently arrived to assist with visit. The facility is license to serve (6) elderly residents ages 59 and older. The fire clearance is approved for (5) non-ambulatory and (1) bedridden resident in room #4. Approved Hospice waiver for (6). Currently there are 4 residents over the age of 60.

Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: (5) residents' rooms, (2) bathrooms, (1) staff room (1) staff bathroom, a living area, a dining area, a kitchen, an outside seating area and a garage Back Yard, Ramps and Outside table with shade.

Physical Plant LPA and Staff Alvin Geniza toured the facility inside and outside. LPA observed 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. Bed linens, comforters, and bath towels were available. Bathrooms were operational with water temperature measured at 111.2 F. A comfortable temperature of 75 degrees F. was maintained in the facility.

Page 1 of 3

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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 4
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: DIVINE LIFE GUEST HOME
FACILITY NUMBER: 198320397
VISIT DATE: 12/05/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Bedrooms LPA inspected all (5) bedrooms. All bedrooms were observed to have the required furniture including beds, dressers, night stands 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. The water temperature measured 111.2-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.

Kitchen/Laundry Room LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, dishwasher, washer, dryer, refrigerator, LPA observed an ample supply of 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. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. Washer and dryer located back hall of the facility.

page 2 of 3

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: DIVINE LIFE GUEST HOME
FACILITY NUMBER: 198320397
VISIT DATE: 12/05/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Common Rooms In the living room, LPA observed, ample seating for all residents. In the dining room, LPA observed a rectangle table and chairs to accommodate all residents. The facility is maintained at a comfortable temperature. Safety LPA observed and tested smoke/carbon monoxide detectors to be fully operable. LPA observed an addition Carbon Monoxide detector in the hallway. LPA observed 2 fully charged fire extinguisher mounted on the wall, last serviced on 6/29/24. LPA inspected the First Aid kit and found it contained an ample supply of required items. LPA observed the required posting in the facility. LPA observed all exits to be clear and easily accessible. There are no firearms or ammunition stored on the premises.

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

Files/postings LPA reviewed four (4) resident files and found that 4 out of 4 contained all the necessary documentation. LPA reviewed four (4) staff files and found that 2 out of 4 contained the required documentation, certification, and training. LPA observed all required posting.

Infection Control During the visit, LPA observed the facility’s infection control practices.

There were 2 deficiencies issued during this visit. Deficiencies are documented on the 809D.

Exit interview conducted with Administrator Rodrigo Rosaldo and copy of report and appeals right provide.

page 3 of 3

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/05/2024 03:16 PM - It Cannot Be Edited


Created By: Deborah Lee On 12/05/2024 at 02:04 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: DIVINE LIFE GUEST HOME
FACILITY NUMBER: 198320397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews and record reviews. The licensee did not ensured that S1 was criminally cleared prior to working at this facility. Which poses a potential health & safety and personal rights risk to clients in care.
POC Due Date: 12/19/2024
Plan of Correction
1
2
3
4
The administrator agreed have S1 cleared and associated to facilty by due date.
The adminstrator agreed to develop a plan for future compliance.
Request Denied
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews and record reviews. The licensee did not ensured that S2 criminal record clearance was tranferred to the facility prior to working at this facility. Which poses a potential health & safety and personal rights risk to clients in care.
POC Due Date: 12/19/2024
Plan of Correction
1
2
3
4
The administrator agreed have S2 cleared and associated to facilty by due date.
The adminstrator agreed to develop a plan for future compliance.
The administrator stated that he applied for the tranfer of S2 to be associated to facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Deborah Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4