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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320499
Report Date: 11/07/2024
Date Signed: 11/07/2024 12:51:24 PM

Document Has Been Signed on 11/07/2024 12:51 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MIRALESTE HILLS LIVING LLCFACILITY NUMBER:
198320499
ADMINISTRATOR/
DIRECTOR:		CINCO, TINAFACILITY TYPE:
740
ADDRESS:2720 COLT RDTELEPHONE:
(424) 267-6044
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 0DATE:
11/07/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Tina CincoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 11/07/2024, the department conducted a scheduled Pre-Licensing visit to the facility listed above. The department met with Licensee/Administrator Tina Cinco and the purpose of today’s visit was explained. The facility was granted fire clearance on 10/10/2024 from the local fire department for two (2) ambulatory residents, three (3) non-ambulatory residents, and one (1) bedridden resident.
Physical Plant/Structure The facility is a single-story home in a residential neighborhood. It consists of three (3) resident rooms, staff room, kitchen, dining room, living room, siting room, office area, attached garage, and outside sitting area. The outside sitting area has shaded patios with chairs and a table. The department observed a pool and hot tub that has a fence around it and is inaccessible to residents. All walkways around the home were observed clean, clear, and free of debris, obstructions, and hazards. The fences open easily from the inside to easily exit.
Bedrooms The department inspected the three (3) resident bedrooms and found them to be clean and in good repair. The department observed the bedrooms have the required furniture including a bed, dresser, nightstand with a lamp, chairs, and ample storage space for residents’ personal belongings. The department observed the beds have the required linens including a mattress cover, fitted sheets, blanket,
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MIRALESTE HILLS LIVING LLC
FACILITY NUMBER: 198320499
VISIT DATE: 11/07/2024
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comforter, and pillows. The department observed an ample supply of linens in a cabinet in the hallway in good repair.
Bathrooms The department inspected the three (3) bathrooms in the facility. All bathrooms were found to meet Title 22 regulations. All bathrooms were observed operable. The showers were observed clean, and clear of mold or mildew. The showers had secured safety handrails, nonskid mats, and shower chairs in the showers. The water temperature measured between 110.7- degrees and 111.2- degrees Fahrenheit. The department observed hygiene products in the bathroom for residents. LPA observed an ample supply of towels in a cabinet in the hallway and an additional supply stored in residents’ closets.
Kitchen The department inspected the kitchen and found it to be clean and sanitary. All appliances were observed to be in good repair and are operable. The department observed an ample supply of cookware, dishware, and cutleries. The department observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods properly packaged and stored. Additionally, the department observed an additional supply of perishable stored in the garage, and an additional supply of non-perishable foods in a refrigerator in the garage. All knives and sharps were observed secured in a locked drawer in the kitchen and are inaccessible to residents. All cleaning supplies were observed secured in a locked cabinet under the kitchen sink and are inaccessible to residents. An additional supply of cleaning products were observed secured in the locked garage and are inaccessible to residents. The water temperature measured 109.5-degrees Fahrenheit.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MIRALESTE HILLS LIVING LLC
FACILITY NUMBER: 198320499
VISIT DATE: 11/07/2024
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Common Rooms The department inspected all rooms in the facility. The dining room has a large table with chairs to accommodate all residents. The living room has two large couches and three (3) recliners to accommodate residents. The sitting area has a large couch and chair available for resident use. The office area has a desk and file cabinet. The department observed games, activities, crafts, and reading material available for resident use. All rooms and hallways were observed with ample lighting. All walkway and hallways inside the facility were observed clean, clear, and free of obstructions and hazards. The facility was maintained at a comfortable temperature. The department observed fireplaces inside the facility that are screened and inaccessible to residents.
Medications/Files The department observed a locked cabinet in the kitchen where Centrally Stored Medications are going to be secured, and inaccessible to residents. The Administrator plans to use a Medication Administration Record (MAR) to document medication distribution that will be secured in a locked cabinet in the kitchen and will be inaccessible to residents. Resident and Staff files are going to be secured in a locked cabinet in the kitchen and will be inaccessible to residents.
Safety The department observed a fully charged fire extinguisher mounted on the wall in the kitchen, purchased on 05/29/2024. The smoke and carbon monoxide detectors are hardwired and fully operational. The department observed a facility sketch posted in a hallway. The department inspected the First Aid Kit and found it contained the required items and had a current manual. The facility has a working landline telephone. The department observed all required postings posted in the facility including the Administrator Certificate, Resident Right, Emergency Disaster
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MIRALESTE HILLS LIVING LLC
FACILITY NUMBER: 198320499
VISIT DATE: 11/07/2024
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Plan, Emergency Numbers, sample Menu, Activity Schedule, Theft and Loss Policy, Resident Council Right, Ombudsman poster, and Licensing Complaint poster.
Infection Control During the visit, the department observed the facility’s infection control practices. At the entrance of the facility, the department observed a sanitizing station that consist of a visitor sing-in log, hand sanitizer, and face masks. The department observed an ample supply of hand soap and paper towels. The department observed Infection Control signs posted throughout the facility. LPA observed a 30-day supply of Personal Protective Equipment (PPE) stored in the garage.

Component III was reviewed and discussed with Licensee/Administrator.

The department did not observe any corrections.

An exit interview was conducted with Licensee/Administrator, Tina Cinco, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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