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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320472
Report Date: 09/14/2025
Date Signed: 09/14/2025 03:18:17 PM

Document Has Been Signed on 09/14/2025 03:18 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: 6DATE:
09/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:42 AM
MET WITH:Jun Fausto FigueroaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On September 15, Licensing Program Analyst (LPA), Deborah Lee conducted an unannounced annual required visit using the CARE Inspection Tool. LPA Lee met with Jun Fausto Figueroa and the purpose of today’s visit was explained. This facility is licensed to serve 6 non-ambulatory residence over 60 years old. A total of 6 residents are currently residing in this facility. There is a hospice waiver for 6.

Physical Plant/Structure :

The facility is a single-story home located in a residential neighborhood. The entry way of the home is clear and free of debris and obstruction. The home has dual entry doors that open into a foyer. 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 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.

Bedrooms:

LPA inspected all 5 bedrooms; the mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked.

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NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2025
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: VILLA MARCOSA
FACILITY NUMBER: 198320472
VISIT DATE: 09/14/2025
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Bathrooms:

Toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries are accessible to residents. LPA tested hot water temperature, and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as non-medicated soap, toilet paper, toothbrush, toothpaste shampoos, lotions.

Common Rooms:

The living room is fully furnished with sofa, 2 chairs, coffee table, 3 recliners and mounted TV. There is adequate space for activities.

Required Postings:

LPA observed all required documents posted throughout the facility. The facility has a working landline telephone.

Kitchen

LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, dishwasher, refrigerator. LPA observed an ample supply of cutlery, pots, pans, and bowls to be in good repair. LPA observed knives and additional sharps to be secured in garage area and are inaccessible to residents. LPA observed a 2-day supply of perishable foods, and a 7-day supply of non-perishable foods properly stored, packaged, and labeled.

First aid kit is fully stocked with the required items and a manual.

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NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2025
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: VILLA MARCOSA
FACILITY NUMBER: 198320472
VISIT DATE: 09/14/2025
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Safety

LPA observed 2 charged fire extinguishers last serviced on 7/3/24 The last emergency drill was conducted on 5/14/2025. Smoke detectors were tested and operable.

File Review:

LPA reviewed 6 resident files and found that 6 out of 6 had the required documents. LPA reviewed 3 staff files and found that 3 out 3 had the required documents, training, and certifications.

LPA reviewed a copy of the facility’s Liability Insurance with expiration date of 9/25/26

Medications

LPA observed all centrally stored medications secured All medications were observed in their original packaging.

Infection Control

LPA observed required infection control signs posted throughout the facility. LPA observed sanitizing station in the entry way of facility. LPA observed an ample supply of PPE on hand for use when needed.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills.

Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

During today’s visit there were no deficiencies.

An exit interview was conducted with Jun Faust Figueroa and a copy of this report was provided.

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NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2025
LIC809 (FAS) - (06/04)
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