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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320472
Report Date: 08/23/2024
Date Signed: 08/23/2024 12:19:12 PM

Document Has Been Signed on 08/23/2024 12:19 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:VILLA MARCOSAFACILITY NUMBER:
198320472
ADMINISTRATOR/
DIRECTOR:		MATUTE ROSITA FFACILITY TYPE:
740
ADDRESS:1135 E AMELIA DRIVETELEPHONE:
(562) 257-0563
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 6CENSUS: 0DATE:
08/23/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Rosita MatuteTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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On August 23, 2024 at 9:00am, Licensing Program Analyst (LPA), Deborah Lee conducted an announced visit to the facility for the purpose of conducting a pre-licensing evaluation. An application was submitted to CCLD on August 15, 2024 for opening a new facility for an Adult Residential Care Facility for the Elderly (RCFE) to serve 6 clients 60 years and over. Hospice waiver granted for 6. LPAs met with Rosita Matute Licensee and Novela Punzalan, Assistant Admintrator, and explained that the purpose of today’s visit together toured the physical plant(inside and outside).

Overview of Facility:

Facility is a mid-century single story home located in a residential neighborhood. The entry way of the home is clear and free of debris and obstruction. The home have dual entry doors that opens into a foyer. There is a sanitation station as you enter the facility. There are 5 resident bedrooms, 3 1/2 bathrooms, dining room, living room, laundry room off of kitchen area. There is an attached garage. The client bedrooms are spacious and easily accommodate the client's furnishings. The facility has a pool that is gated with required locking on the gate. According to licensee, the pool will not be accessible to residents, as it is a "show piece" feature of the house. The shaded area and outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPAs did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms Residents: Bedrooms 1-5 have working lights, new blinds and working windows with no bars. Only 1 of the 5 bedrooms will be shared, the rest are will be private rooms. Bathrooms: All Bathrooms have a working toilet, wash basins and shower, and observed to be clean, safe, and sanitary. LPAs observed adequate lighting in throughout the entire facilty Linens & Hygiene Supplies: Extra linens are in hallway closet.

Living room is fully furnished with sofa, 2 chairs, coffee table, and mounted TV. There is adequate space for activities.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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 2
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: VILLA MARCOSA
FACILITY NUMBER: 198320472
VISIT DATE: 08/23/2024
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The dinning area is equipped with a large square dinning set that seats 6-8 comfortably. Facility has a lanline phone for emergencies. There are two fully charged fire Extinguishers located in the kitchen and living room areas. LPA observed all required postings.

Smoke Detectors: Facility has 7 smoke detectors/carbon monoxide detectors are hardwired and interconnected. They were tested and operable. Appliances: LPA observed all kitchen appliances and washer and dryer in working order. LPA observed a 7 day supply of non perishables and 2 day supply of perishable. The residence is equipped with heat and air conditioning. Toxins: Applicant showed LPAs, where toxins to be locked/stored: In locked cabinet above washer and dryer in laundry room. Water Temperature: Tested at 110.9 degrees F. Clients & Staff Files: will all be stored in locked area in hall closet.



There are no corrections needed.

Component III: Conducted during today’s Pre-Licensing visit

A copy of this reported provided to Licensee Rosita Matute
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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