198320474-7-11-2024-11-AS-MLEN-D73RTH-20240711131823

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320474
Report Date: 07/11/2024
Date Signed: 07/11/2024 01:19:28 PM

Document Has Been Signed on 07/11/2024 01:19 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:	FAMILY CONNECT MEMORY CARE PALOS VERDES		FACILITY NUMBER:	198320474
ADMINISTRATOR/ DIRECTOR:	MAHAKIAN, LAUREN		FACILITY TYPE:	740
ADDRESS:	28873 BLYTHEWOOD DR		TELEPHONE:	(310) 383-1877
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY: 6		CENSUS: 0	DATE:	07/11/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:59 AM
MET WITH:	LAUREN MAHAKIAN		TIME VISIT/ INSPECTION COMPLETED:	01:45 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 07/11/2024 Licensing Program Analyst (LPA) Mario Leon conducted an announced visit to the above-mentioned facility using the CARE tool. LPA was greeted by applicant Lauren Mahakian, Administrator, and LPA explained the purpose of today’s pre-licensing inspection visit. An application was submitted to Community Care Licensing Division (CCLD) on 03/26/2024 for the initial license application for a Residential Facility for the Elderly (RCFE), ages 60 years and above. The applicant requested a capacity of six (6) individuals, of which six (6) may be non-ambulatory and zero (0) bedridden residents. Structure: The facility is a one-story residential home, located in a residential neighborhood. The facility consists of four (4) bedrooms, two-and-a-half (2.5) bathrooms. The facility has a two (2)-car garage, which is designated as a staff break-room. The garage has ample emergency water and an emergency bin which contains additional lighting and a can opener, among other emergency supplies. In the garage there are two (2) mini-fridges. One (1) mini-fridge is designated for refrigerated medicines and one (1) mini-fridge is designated for staff usage. The home includes a living room, dining room, kitchen, and laundry area. The living room has one (1) fireplace, adequately screened. The living area includes six (6) recliner chairs, each with a side table. The kitchen has a refrigerator, microwave, stove and various appliances located on the counter. The rear exterior has two (2) shaded seating areas, one (1) private family seating area and is fenced throughout. All passageways and walkways are free from obstructions. Bedrooms: The facility has four (4) bedrooms for residents. Two (2) rooms are private and two (2) rooms are shared, all rooms are for non-ambulatory residents. All rooms include a twin-sized bed, one (1) chair, one (1) night stand, and one (1) table lamp. All bedrooms are equipped with a ceiling light. All rooms have a closet, which complies with the requirement of 8 cubic feet of space for each residents' belongings. All rooms also include wall night lights. Report Continues, see LIC809C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

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: FAMILY CONNECT MEMORY CARE PALOS VERDES	FACILITY NUMBER: 198320474
	VISIT DATE: 07/11/2024

NARRATIVE

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Bathrooms:
The home has two-and-a-half (2.5) bathrooms, of which the half-bath (0.5) is designated for staff usage. Two (2) bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid strips.

Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets and blankets. An adequate supply of additional linen is stored in the northernmost hall closet, located at the end of the hallway.

Emergency Phone Numbers, Exit Plan & Menu:
The exit plan and menu are posted and readily available for review, located on the entry cork board. There are two (2) fire extinguishers, fully accessible to staff and one (1) fire extinguisher located in the garage, all which are mounted on the wall. All fire extinguishers are fully charged, with purchase receipt(s) dated 03/10/2024. A telephone line is available, with two (2) phones located in the kitchen. Emergency supplies and Personal Protective Equipment supplies are stored in the garage. The applicant has an approved Emergency and Disaster Plan on file, and can also be located on the entry cork board.

Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives and other sharp kitchen utensils are stored in a locked kitchen cabinet, above the microwave. Food supply is adequately stored and consists of seven (7)-days supply of non-perishable foods and two (2)-day supply of perishable food. The kitchen counters also had small appliances.

Smoke Detectors:
Seven (7) smoke and carbon monoxide detectors were located throughout the interior space. There is one (1) detector in each bedroom and the remainder are located in the hallway, dining and living room. All detectors are hardwired, with battery back-up, and in working order.

Toxins:
All detergents and toxins are locked and stored in the garage.
Report Continues, see LIC809C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC809 (FAS) - (06/04)

Page: 2 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: FAMILY CONNECT MEMORY CARE PALOS VERDES	FACILITY NUMBER: 198320474
	VISIT DATE: 07/11/2024

NARRATIVE

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Appliances:
Stove burners, oven, microwave, washer, and dryer are in working order. The kitchen counters also had small appliances which includes oven toaster, built-in microwave oven, blender and a coffee maker. There are three (3) refrigerators in the home. The main refrigerator, located in the kitchen, measured a temperature of at least 40 degrees F for appropriate food storage. The home has central AC/Heat, with additional electric fans stored in the garage.

Water Temperature:
The water temperature was measured at 116.3 degrees F in bathroom number one (#1) and Kitchen was measured at 117.5 degrees F. All water temperatures are within Title 22 regulation.

Medications, First-Aid Kit & Book:
A first aid kit is stored in the medication cabinet, located in the kitchen. First-aid kit was inspected and has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and a current first aid manual and is locked and inaccessible to residents. The resident's medications will be centrally-stored in a cabinet, located in the kitchen, locked and inaccessible to residents.

Resident & Staff Files:
The applicant is not handling the cash resources for residents. Records of staff and residents will be stored in cabinets, located in the kitchen area.

Reading Material, Games, Equipment & Materials:
The facility has board games, art supplies, music-therapy devices, ping-pong table, mini-golf and additional recreational materials, for the resident's use, all stored in the living room and living room closet.

Pool/Jacuzzi & Pets:
There are no pets, nor any body of water located on-site.

Report Continues, see LIC809C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC809 (FAS) - (06/04)

Page: 3 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: FAMILY CONNECT MEMORY CARE PALOS VERDES	FACILITY NUMBER: 198320474
	VISIT DATE: 07/11/2024

NARRATIVE

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Fire clearance:
A Fire Clearance inspection was conducted on 06/27/24 and the above-mentioned facility was approved for a capacity of six (6) non-ambulatory residents in all rooms (rooms number 1-4).

Component III:
LPA conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with the Component III PowerPoint.

An exit interview was conducted, and a copy of this report has been furnished to the applicant Lauren Mahakian. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

Pre-Licensing is complete and this facility has no deficiencies.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC809 (FAS) - (06/04)

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