198320487-7-28-2025-11-AS-ZBRN-DJZTL2-20250728144848

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320487
Report Date: 07/28/2025
Date Signed: 07/28/2025 02:48:57 PM

Document Has Been Signed on 07/28/2025 02:48 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:	PEPPERWOOD VILLA		FACILITY NUMBER:	198320487
ADMINISTRATOR/ DIRECTOR:	UMANA, JOSE		FACILITY TYPE:	740
ADDRESS:	4224 PEPPERWOOD AVE		TELEPHONE:	(562) 477-5797
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY: 6		CENSUS: 5	DATE:	07/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Elsa Roman, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:00 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 07/28/2025 at 11:15 am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced visit to the above facility. The purpose of today's visit was to conduct the one-year inspection. LPA met with Elsa Roman, Administrator and the purpose of the visit was discussed. The The facility is licensed to serve 6 non-ambulatory only residents and a waiver granted for an approved hospice care for five (5) residents. Five (5) of the residents are diagnosed with dementia, zero (0) residents receive home health, and one (1) of the residents are receiving hospice care services. The facility does not handle any of the residents’ money. The facility has a current administrator certificate (#7012218740) for Elsa Roman valid from 06/24/2024 - 06/23/2026. The facility fees are current. The facility has liability insurance with James River Casualty Company (NAIC# 13685) with each occurrence at $1,000,000 and general aggregate at $3,000,000 (policy #00150009-1) effective date 11/17/2024 - 11/17/2025. The facility fees are current. The home is a single home consisting of : (5) resident bedrooms, (2) full bathrooms, living room, a kitchen, a washer and dryer area, a dining area, a living room, a backyard with two (2) shed with additional storage and an outdoor shaded patio are in the backyard. Report continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025

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: PEPPERWOOD VILLA	FACILITY NUMBER: 198320487
	VISIT DATE: 07/28/2025

NARRATIVE

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Between the hours 11:29 am - 11:52 am, LPA toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. The water temperature measured at 112.5°F (in the kitchen), 112.5 °F (in bathroom #1) and 110.7°F (bathroom #2). Resident bath towels, toiletries, and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards doorways were free of obstructions.

Between the hours of 11:52 am - 2:30 pm, LPA conducted a records review of (5) residents records, (5) staff records and (5) Client Medication Administration Records and the facility disaster plan. All client & staff records were complete. The facility disaster plan was current (last conducted on 07.08.2025) and in compliance with Title 22 at the time of visit. LPA did not observed any discrepancies at the time of visit.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous Items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

During today’s visit LPA did not observe any deficiencies.

An exit interview was conducted with Elsa Roman (Administrator) and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025

LIC809 (FAS) - (06/04)

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