198320532-1-15-2025-11-AS-MLEN-DCXTZZ-20250115141111

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320532
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:11:25 PM

Document Has Been Signed on 01/15/2025 02:11 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:	KINAH MAE HOME RPV		FACILITY NUMBER:	198320532
ADMINISTRATOR/ DIRECTOR:	CRUZ, RENETTE DE LA		FACILITY TYPE:	740
ADDRESS:	27811 PALMERAS PL		TELEPHONE:	(310) 720-7080
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY: 6		CENSUS: 0	DATE:	01/15/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:11 AM
MET WITH:	Renette De La Cruz, Licensee		TIME VISIT/ INSPECTION COMPLETED:	02:29 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 01/15/2025 The Department of Social Services, Community Care Licensing Division (CCLD) staff conducted an announced visit to the facility for purpose of a pre-licensing evaluation. Today’s pre-licensing evaluation was held, in-person, with staff one Renette De La Cruz, Administrator (S1). On 07/31/2024 an application was submitted to CCLD, for an initial license for a Residential Care Facility for the Elderly to serve Elderly adults from ages 60 and above. Requested capacity is for six (6) clients of which five (5) may be non-ambulatory and one (1) client who is bedridden. The facility has a hospice waiver for six (6) clients in care. The facility is a single-story home which includes four (4) bedrooms, two “half-bath” (2) bathrooms, one (1) kitchen, (1) dining room, one (1) living room, with an attached garage, and is located within a residential neighborhood. CCLD staff conducted a review of the Physical Plant, Bedrooms, Bathrooms, Supplies, Food Service, Medications, Records, Administration, Activities, Pre-Licensing Checklist and Component III Orientation with S1. MEDICATIONS There is a locked centralized storage area for client medications. PHYSICAL PLANT Facility is clean, sanitary, and in good repair. Protective devices are in place to include fire prevention and mitigation and all are operational. Indoor and outdoor passageways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. There is one (1) pool, located in the back yard with a locked 5ft-high fence surrounding the water, making the water inaccessible to residents in care. There are locked storage areas for poisons, pool chemicals and sharps. All window screens are clean and in good repair. Facility maintains a comfortable temperature at 77.5 degrees F. The facility has central air. Inclines, ramps, open porches, and areas of potential hazard are well-lit and adequately equipped for elderly residents. Nine (9) smoke detectors are hard wired and operate properly. Two (2) Carbon monoxide detectors operate properly. S1 shut off the facility power source to indicate emergency lighting as operational. Report continues, see LIC809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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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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: KINAH MAE HOME RPV	FACILITY NUMBER: 198320532
	VISIT DATE: 01/15/2025

NARRATIVE

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BEDROOMS
Halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings are not being used as client bedrooms. Client bedrooms are large enough to allow for easy passage and to accommodate furniture and assistive devices such as wheelchairs, walkers, or oxygen equipment. No client bedroom is a passageway to another room, bath or toilet and each room’s overhead light and fan are in working condition. There is a bed for each client with a bedspring, mattress, waterproof cover, fitted sheets, flat sheets, two (2) blankets and pillow covers which are clean and in good repair. Mattresses and pillows are flame-retardant. Each resident has their own chest of drawers in addition to closet space that includes at least two (2) drawers and eight (8) cubic feet of dresser space per client. Two (2) private use bedrooms host one (1) chair, (1) bedside table and one (1) reading lamp. Two (2) shared bedrooms each include two (2) chairs, one (1) bedside table and one (1) reading lamp.
BATHROOMS
Bathroom #1 is for client use and has one (1) toilet, two (2) washbasins and one (1) shower and the water temperature was measured at 115.1ºF. Bathroom #2 has one (1) toilet, one (1) washbasin and one (1) shower available for client, family, and personnel use and the water temperature was measured at 113.5 ºF. All bathrooms are located near client bedrooms, were observed to be without mold and comply within title 22 regulations. There are nightlights throughout the facility and emergency lighting was observed in operation.
SUPPLIES
There are client personal hygiene supplies which included feminine napkins, soap, shampoo, toothbrush, toothpaste, and additional paper supplies and Personal Protective Equipment (PPE). There is a sufficient supply of clean linens to permit weekly changing, or more, of client’s bedding, located within each room’s closet which include top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers and CCLD also observed ample bath towels, hand towels, and washcloths which are located in the hallway dresser.
FOOD SERVICE
The Dining room is near the kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer has been marked as 0ºF on the Daily Temperature Report for refrigerator and freezer. Refrigerator temperature log shows an average of 37 ºF and a Daily Temperature Report is stored nearby. A seven (7) day supply of non-perishable food is present. There are adequate tableware, tables, dishes, and utensils while hosting six (6) clients in care. There are equipment for the storage, preparation, and service of food to clients in care. All equipment, dishes, and utensils are clean and well maintained. Report continues, see LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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: KINAH MAE HOME RPV	FACILITY NUMBER: 198320532
	VISIT DATE: 01/15/2025

NARRATIVE

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All kitchen, food storage, and preparation areas are clean and food items are labeled by date of purchase by S1.
RECORDS
There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility. Both have been observed as locked.
ADMINISTRATION
The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Facility Visiting Policy is posted within the Admissions Agreement and nearby other mandated reporting poster(s). Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings.
ACTIVITIES
There is a shared outdoor activity space with shaded areas and are furnished for outdoor use. There is at least one common room available to clients for visitors. There are activity supplies which include newspapers, magazines, and a variety of reading material as well as a variety of different types of “stress ball” present.
MISCELLANEOUS
There are first-aid supplies which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies are present, which includes flashlights with batteries. Vehicles used to transport clients are in safe operating condition.
PRE-LICENSING CHECKLIST has been completed by licensee via Central Applications Bureau (CAB) and was reviewed by CCLD staff.
COMPONENT III was provided via PowerPoint presentation; information was provided about how to operate the facility within substantial compliance.
During the pre-licensing inspection, CCLD observed the liability insurance total aggregate at two-million (2,000,000) dollars (2M) which is below standards noted under Health and Safety Code (HSC) 1569.605. HSC1569.605 requests a facility to hold a total aggregate at three-million (3,000,000) dollars (3M). S1 and CCLD contacted witness one (W1), insurance agent. W1 confirmed that the total aggregate will be increased to 3M dollars prior to residents moving into this facility. CCLD marked this as a technical violation, as CCLD observed and received a verbal confirmation to increase the total aggregate to 3M prior to residents moving into this facility. Please see LIC9102-TV.
Report continues, please see LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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: KINAH MAE HOME RPV	FACILITY NUMBER: 198320532
	VISIT DATE: 01/15/2025

NARRATIVE

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There have been zero (0) deficiencies cited during today's visit.

An exit interview was conducted, and a hard copy of this report has been provided to Renette De La Cruz (S1).

Accordingly, 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 the applicant.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

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