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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320407
Report Date: 12/19/2024
Date Signed: 12/19/2024 12:43:46 PM

Document Has Been Signed on 12/19/2024 12:43 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/
DIRECTOR:		KLEIN, STEPHANIEFACILITY TYPE:
740
ADDRESS:24608 PENNSYLVANIA AVENUETELEPHONE:
(310) 947-2165
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 5CENSUS: 3DATE:
12/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:33 AM
MET WITH:Ricarte LapuzTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On December 19, 2024, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced required annual visit using the CARE Inspection Tools. LPAs met with Ricarte Lapuz, Assistant Administrator and explained the purpose of this visit. The facility is licensed to operate for (5) ambulatory Residents. The facility is approved for (2) hospice residents. There are currently 3 residents in care.

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.

Physical Plant LPA and Ricarte Lapuz 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. LPA observed that facility had required postings: ombudsman poster, see something say something poster, emergency numbers, clients rights, facility sketch.
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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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: PEPPER TREE ASSISTED LIVING III
FACILITY NUMBER: 198320407
VISIT DATE: 12/19/2024
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Bedrooms LPA inspected all 3 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 bathroom. 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 105.4-degrees Fahrenheit. The toilet and faucets are operational. The bathroom was 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.

Kitchen/Laundry Room LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, washer, dryer located in garage. 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. Cleaning products and toxins were secured in garage that is inaccessible to clients.

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

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
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: PEPPER TREE ASSISTED LIVING III
FACILITY NUMBER: 198320407
VISIT DATE: 12/19/2024
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Common Rooms In the living room, LPA observed sofa, 3 chairs, mounted TV. In the dining room, LPA observed a 6 seated dinning table

Safety LPA observed and tested smoke/carbon monoxide detectors to be fully operable. LPA observed (1) fully charged fire extinguisher mounted on the wall, last serviced on 10/11/24. LPA inspected the First Aid kit and found it contained an ample supply of required items: Scissors, tweezers, gauze, disinfectant wipes, band aids and a manual. LPA observed all exits to be clear and easily accessible. There are no firearms or ammunition stored on the premises.

Due to time constraints LPA to complete inspection on a subsequent visit.

There were no deficiencies cited during today’s inspection.

Exit interview conducted and copy of this report given to Ricarte Lapuz.

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

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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