198320532-1-14-2026-11-AS-MLEN-DQBTME-20260114135102

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320532
Report Date: 01/14/2026
Date Signed: 01/14/2026 01:51:10 PM

Document Has Been Signed on 01/14/2026 01:51 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, 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:	3107207080
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY: 6		CENSUS: 3	DATE:	01/14/2026
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:14 PM
MET WITH:	Renette De La Cruz		TIME VISIT/ INSPECTION COMPLETED:	02:00 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 01/14/26 Licensing Program Analyst (LPA) Mario Leon conducted a required annual visit at the facility. Upon entrance, LPA was met by staff one, Renette De La Cruz - Licensee (S1) and the purpose of the visit was explained. The facility is a single-story home located in a residential neighborhood, which consists of the following: 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. Facility maintains all required posting throughout the facility. LPA reviewed both resident files and found that they contained all required documents. LPA reviewed two (2) staff files and found they contained the required documents, and trainings. LPA reviewed their Liability Insurance. LPA reviewed the training logs for staff. The facility has a current census of three (3) residents (R1-R3). S1 and LPA toured the facility, inside and out. 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, please see LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

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: KINAH MAE HOME RPV	FACILITY NUMBER: 198320532
	VISIT DATE: 01/14/2026

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.

During today's inspection, LPA observed four (4) staff present. Upon review of Personnel Summary, there are only two (2) staff associated. When asked about the additional staff, S1 informed LPA that the two (2) additional staff's association has been mailed to Sacramento during the prior week. LPA did not cite, as the two (2) staff's paperwork are also being held at the facility. LPA created a technical violation, please see LIC9102TV.

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

An exit interview was held with Renette De La Cruz and a copy of this report has been provided.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

LIC809 (FAS) - (06/04)

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