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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320408
Report Date: 05/11/2026
Date Signed: 05/11/2026 04:57:56 PM

Document Has Been Signed on 05/11/2026 04:57 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 VILLAFACILITY NUMBER:
198320408
ADMINISTRATOR/
DIRECTOR:		BERNARDO, PAMELAFACILITY TYPE:
740
ADDRESS:430 W 109TH PLACETELEPHONE:
(323) 574-3841
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY: 6CENSUS: 2DATE:
05/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:13 PM
MET WITH:Rayjennia Adams-Administrator TIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct an annnual inspection. Upon arrival LPA met with Rayjennia Adams, Administrator and she was informed of the purpose of the visit.

Facility is licensed to serve 6 non- ambulatory residents age 60 and over of which (1) maybe bedridden . The facility has an approved hospice waiver for (6) residents. Currently there are two (2) residents in care and both are receiving home health care.

This home is a single story home consisting of: four (4) bedrooms, (2) Full bathroom, living room, kitchen with dining area, laundry room and an outdoor shaded patio area.

At 2:45 PM, LPA toured the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident. The bathrooms toilets and faucets were in working condition, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, the water temperature measured between 105- 118.1 F. There was adequate bath towels, toiletries and personal hygiene supplies available. The common areas appeared to be clean and free of hazards; doorways were free of obstructions.

LPA Allen observed that facilities kitchen to have a 5-day supply of perishables and a 7-day supply of non-perishables food items for the number of residents in care which were stored and maintained properly.

There was also a storage area for additional cleaning supplies, and toxins which were inaccessible to clients.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Bernadette Allen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/11/2026
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At LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings, which appeared to be current and two (2) clients files for admission agreements, updated physician reports, needs and services plan which appeared to be up to date.

Smoke/carbon monoxide detectors were observed to be fully changed, tested and operating. The fire extinguishers were fully charged, and the last fire drill and emergency drill was conducted on 4/5/2026.

During the inspection LPA Allen did not observe deficiencies therefore no citations were issued.



An exit interview was conducted, where this report was discussed and provided to Rayjennia Adams- Administrator at the conclusion of the visit.
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Bernadette Allen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
LIC809 (FAS) - (06/04)
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