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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320407
Report Date: 01/16/2025
Date Signed: 01/16/2025 03:11:04 PM

Document Has Been Signed on 01/16/2025 03:11 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:
01/16/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:33 PM
MET WITH:Ricarte LapuzTIME 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 January 16, 2025 Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced Case Management Continuation inspection to complete inspection that was started on 12/19/2024. LPA 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.

Files/Postings

LPA reviewed three (3) staff files and found that ( 3) out of (3 ) contain the required documents, certification, and training. LPA reviewed (3) client files and found that ( 3 ) out of (3) contained the required documents. LPA observed all required posting including license, personal rights, “see something, say something,” activity schedule, infection control signs. During file review, LPA observed all licensing fees are current. No deficiencies were cited during inspection. LPA conducted final interview with House Manager, Ricarte Lapuz , and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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 1