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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320407
Report Date: 11/16/2023
Date Signed: 11/16/2023 02:18:55 PM

Document Has Been Signed on 11/16/2023 02:18 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:PEPPER TREE ASSISTED LIVING IIIFACILITY NUMBER:
198320407
ADMINISTRATOR:KLEIN, STEPHANIEFACILITY TYPE:
740
ADDRESS:24608 PENNSYLVANIA AVENUETELEPHONE:
(310) 947-2165
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 6CENSUS: 0DATE:
11/16/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:STEPHANIE KLEINTIME COMPLETED:
02:40 PM
NARRATIVE
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On 11/16/2023 at 10:30 AM, Licensing Program Analyst (LPA) Lourdes Montoya conducted an announced pre-licensing visit to this home. LPA was greeted by Applicant Stephanie Klein and Staff Marhlyn Sapugay and explained the purpose of today’s pre-licensing inspection visit.

An application dated 8/25/2023 was submitted to CCLD for an initial application for a Residential Care Facility for Elderly License. The applicant requested a capacity of six (6) ambulatory individuals. However, due to insufficient space on one of the bedrooms (bedroom #1), applicant agreed to reduce the capacity to five (5) ambulatory individuals. A new fire clearance for five ambulatory individuals was obtained on today's visit.

Structure:
The facility is on the second floor of a two-story house located in a residential neighborhood and consists of three (3) bedrooms, one (1) bathroom, living room, dining area, a kitchen, and a covered outdoor patio and a garage on the first floor. The facility is clean and sanitary. Indoor passageways are free of obstructions. All window screens are clean and in good repair. The facility temperature is between 68 degrees and 85 degrees.

Bedrooms (Residents):
The facility has three (3) bedrooms for ambulatory clients. Client bedrooms are large enough to allow for easy passage and to accommodate furniture and assistive devices such as wheelchairs, walkers, or oxygen equipment. No client bedroom is a passageway to another room, bath, or toilet.

Bedrooms (Staff):


There is no staff bedroom.

Bathrooms:
The home has one (1) bathroom. The resident bathroom has a working toilet and washbasins.

Evaluation Report Continued in LIC809-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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 3
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: PEPPER TREE ASSISTED LIVING III
FACILITY NUMBER: 198320407
VISIT DATE: 11/16/2023
NARRATIVE
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Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in a cabinet in the bathroom and in the garage.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There is one (1) fire extinguisher located in the dining area. A telephone line (424-263-4636) is available in the living room. Personal Protective Equipment supplies are stored in the garage. The applicant’s Infection Control Plan was approved.

Food Service:
All kitchen areas are clean and free of litter, rodents, vermin, and insects. The refrigerator and freezer are clean and of adequate size. The freezer is maintained at 0 degrees Fahrenheit and the refrigerator is below the required maximum of 40 degrees Fahrenheit. A two (2) day supply of perishable foods and a seven (7) day supply of non-perishable food were observed. All equipment, appliances, dishes, and utensils are clean and well maintained.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space are operable.

Water Temperature:
The water temperature measures 107.8 degrees Fahrenheit in the resident bathroom.

Medications, First-Aid Kit & Book:
The client's medications will be stored in a locked cabinet in the living room.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: PEPPER TREE ASSISTED LIVING III
FACILITY NUMBER: 198320407
VISIT DATE: 11/16/2023
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Clients & Staff Files:
The applicant will not be handling the cash resources of the residents. Records of staff and residents will be stored in a locked cabinet in the living room.

Reading Material, Games, Equipment & Materials:
LPA observed board games, books, magazines, and other recreational materials for the client's use all stored in the living room.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pool in the fenced area.

Fire clearance:
A revised Fire Clearance was obtained on 11/16/2023 with approval for a capacity of five (5) ambulatory individuals.

Component III:
The applicant, Stephanie Klein, completed the Component III during the Pre-Licensing visit on 11/16/2023. Information provided about how to operate the facility within substantial compliance. When the applicant was asked if she understood Title 22, she responded in the affirmative.

An exit interview was conducted, and a copy of this report has been furnished to Applicant Stephanie Klein. LPA Montoya 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.



END OF REPORT
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3