198320408-3-18-2024-11-AS-TWAN-D3GUY2-20240318155912

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320408
Report Date: 03/18/2024
Date Signed: 03/18/2024 03:59:23 PM

Document Has Been Signed on 03/18/2024 03:59 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:	ELISHAMA'S VILLA		FACILITY NUMBER:	198320408
ADMINISTRATOR:	BERNARDO, PAMELA		FACILITY TYPE:	740
ADDRESS:	430 W. 109TH PLACE		TELEPHONE:	(323) 574-3841
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90061
CAPACITY: 6		CENSUS: 2	DATE:	03/18/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	RAYJENNIA ADAMS - LICENSEE		TIME COMPLETED:	04:30 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 03/18/24 Licensing Program Analysts (LPA’s) Socorro Leandro and Troy Watson conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with authorized licensee: RayJennia Adams. The licensee has applied for a license to serve 6 elderly residents ages 60 and older. The fire clearance is approved for 5 non-ambulatory residents and 1 bedridden resident. Bedrooms 1, 2 and 3 are approved for non-ambulatory residents and bedroom 4 is approved for one bedridden resident. A tour of the Kitchen, Dining Room, Living Room, 4 Bedrooms, 2 Bathrooms, 1 attached Garage, 2 Storage units for all supplies, and 1 Patio area were observed and evaluated as being in compliance. The following was observed during this visit: MEDICATIONS: There is a locked centralized storage area for resident medications. Report continues LIC 809C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

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: ELISHAMA'S VILLA	FACILITY NUMBER: 198320408
	VISIT DATE: 03/18/2024

NARRATIVE

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PHYSICAL PLANT: Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 73°F. degrees. Open porches, and areas of potential hazard are well-lit. All 7 smoke alarms operate properly. Carbon monoxide detectors operate properly.

BEDROOMS: There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair. Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes 8 cubic feet of dresser space per client. There is a chair and lamp for each client and at least 1 night stand per client.

BATHROOMS: There is at least 2 toilet and washbasin per 6 clients, family, and personnel. There is at least 2 showers or bathtub per 6 clients and personnel. The hot water temperature is 117.6° Fahrenheit. The bathroom is located near the client’s bedrooms. There are night-lights in the hallways outside non-private bathrooms,

Report continues LIC 809C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

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: ELISHAMA'S VILLA	FACILITY NUMBER: 198320408
	VISIT DATE: 03/18/2024

NARRATIVE

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SUPPLIES: There are clients’ personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths.

FOOD SERVICE: Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least 2 days of perishable foods. Freezer is 0° Fahrenheit. Refrigerator is a maximum of 45° Fahrenheit. A 7 day supply of non-perishable food is present. There are enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

RECORDS: There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility.

ADMINISTRATION: The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. A Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings.

Report continues LIC 809C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

LIC809 (FAS) - (06/04)

Page: 4 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: ELISHAMA'S VILLA	FACILITY NUMBER: 198320408
	VISIT DATE: 03/18/2024

NARRATIVE

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ACTIVITIES: There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors.

MISCELLANEOUS: There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries.

During this pre-licensing inspection, LPA observed corner space in garage occupied by a desk and art supplies. Licensee was asked to remove items located in corner of garage, in which licensee complied. This was the only correction that was needed and immediate corrected by the Licensee. LPA conducted the Component III Orientation with the Licensee and copy of this report was provided. A copy of the facility evaluation report will be available 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 their assigned CAU Analyst.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

LIC809 (FAS) - (06/04)

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