198320430-6-26-2025-11-AS-MLEN-DHZVWA-20250626164736

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320430
Report Date: 06/26/2025
Date Signed: 06/26/2025 04:47:55 PM

Document Has Been Signed on 06/26/2025 04:47 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:	AUNT MONA'S CARE HOME		FACILITY NUMBER:	198320430
ADMINISTRATOR/ DIRECTOR:	MONA MCCALLISTER		FACILITY TYPE:	740
ADDRESS:	2522 SUNNYSIDE RIDGE RD		TELEPHONE:	3107219667
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY: 6		CENSUS: 4	DATE:	06/26/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:16 PM
MET WITH:	Gregg MacEllven, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:02 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 06/26/25 Licensing Program Analyst (LPA) Mario Leon conducted an annual required visit at the facility, using the CARE tool. LPA was met by staff one, Gregg MacEllven - Administrator (S1), and the purpose of today's visit has been explained. The facility is licensed to serve six (6) elderly adults ages 60 and above, of which six (6) may be non-ambulatory and bedridden. The facility has an approved hospice waiver for six (6) residents. The facility is currently hosting four (4) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) bedrooms, three (3) full bathroom with bathing tub, surveillance camera system, ramp alongside back of facility, laundry room/office, living room, fireplace, dining room, shaded back yard with ramp on back porch, front yard with shaded porch, and an attached two-car garage. LPA and S1 toured the physical plant. LPA inspected a total of (6) bedrooms and (3) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were checked and there was no mold or mildew present, water temperature ranged up to 142.4°F, outside Title 22 regulations. Please see LIC809-D. Smoke and carbon monoxide detectors were in operable condition. Smoke detectors are fully charged, as of 05/12/25. The facility's indoor temperature was measured at a comfortable 73.5°F. LPA observed at least 8" square feet (8sqft) for resident personal hygiene supplies, including 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. Dining room is adjacent to kitchen, with seating up to six (6) individuals. Refrigerator(s) and freezer(s) are clean and LPA observed at least two (2) days of perishable foods and a seven (7) day supply of non-perishable food, all stored properly. LPA observed tableware, dishes, and utensils. Report continues, see LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025

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: AUNT MONA'S CARE HOME	FACILITY NUMBER: 198320430
	VISIT DATE: 06/26/2025

NARRATIVE

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Facility Liability insurance is active, set to expire on 12/12/25. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility.

During today's visit, there have been one deficiency cited. Please see LIC809-D.

An exit interview was held with staff one, Gregg MacEllven (S1) - Administrator, and a copy of the facilities' appeal rights, one (1) deficiency cited and this report.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/26/2025 04:47 PM - It Cannot Be Edited

Created By: Mario Leon On 06/26/2025 at 04:21 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AUNT MONA'S CARE HOME	FACILITY NUMBER: 198320430
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above in one (1) out of four (4) water taps measured at 142.4 degrees farenheit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2025
	Plan of Correction
1 2 3 4	Licensee and LPA have agreed that the facility will forward an updated water temperature photo, via email/text, to LPA at Mario.Leon@DSS.CA.GOV / 626.501.2209 on, or prior to POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:

	Mario Leon
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025

LIC809 (FAS) - (06/04)

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