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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320547
Report Date: 09/04/2025
Date Signed: 09/04/2025 05:13:18 PM

Document Has Been Signed on 09/04/2025 05:13 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:HEALING HOMEFACILITY NUMBER:
198320547
ADMINISTRATOR/
DIRECTOR:		BACANI, LILIBETHFACILITY TYPE:
740
ADDRESS:57 EMPTY SADDLE LNTELEPHONE:
(310) 984-0087
CITY:ROLLING HILLS ESTATESTATE: CAZIP CODE:
90274
CAPACITY: 6CENSUS: 0DATE:
09/04/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:02 PM
MET WITH:Alicia RogersTIME VISIT/
INSPECTION COMPLETED:
05:18 PM
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Licensing Program Analyst (LPA) Mario Leon, conducted an announced visit to the facility for purpose of a pre-licensing evaluation.
An application was submitted to CCLD on 10/21/24, for an an initial license for a Residential Care Facility for the Elderly to serve the Elderly for ages 60 and above. The requested capacity is for six (6) ambulatory of which one (1) may be bedridden.
Structure:
Facility is a (4) bedroom, (4) bathroom, single story house with an attached (2) car garage. The facility is a white wood-paneled structure with (4) bedroom, (4) bathrooms, 1 living room, a restaurant style kitchen. The home has a gas fire place in the living room with a metal screen cover, and is inaccessible to clients. There is a large backyard, with a shaded patio area with plentiful seating for residents in care and a front yard with stable. The client bedrooms are spacious and will easily accommodate the client's furnishings. All walkways are either ramped or gated and there have been no obstructions observed during today's visit.
Bedrooms Residents:
– Bedrooms approved for Ambulatory residents only shall not be used for Non-Ambulatory, per 85087.
There shall be no more than two clients per bedroom. Bedrooms #1 are for bedridden residents . Bedroom #(3) and (4) has two beds, two chairs, two night stands, two lamps in addition to overhead lighting and fan. Each room has more than 8 cubic feet of storage per resident.

Report continues see LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025
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: HEALING HOME
FACILITY NUMBER: 198320547
VISIT DATE: 09/04/2025
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Bedrooms Staff:
Bedroom #5 is for live-in staff, with full-bath. No bedroom is designated for awake-staff.
Bathrooms:
All bathrooms have a working toilet, wash basin, and a shower. Bathroom between rooms #(2) and #(3) has one walk-in shower which will accommodate non-ambulatory residents in a wheelchair. Each full-bathroom has a slip-resistant bath mat and all bathrooms host sturdy grab bars.
Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, waterproof mattress pads, fitted sheet, draw sheet, and blanket. Bedspreads and ample linens are stored in the linen closet, located at the South-Western end of the house, closest to the stable.
Emergency Phone Numbers, Exit Plan & Menu:
The facilities telephone system is a landline and is in working condition. Posted & readily available for review in the entryway is the emergency disaster plan, which also displays emergency exit plan. Three (3) Fire Extinguishers are present in the facility with one (1) located near kitchen next to the fridge, one (1) in the entryway, and one (1) in the garage.
Food Service:
Dishes, cups and flatware are stored in the kitchen cupboards, have been inspected and are in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer next to the sink. Food supply is adequately stored in kitchen cabinets and refrigerator. LPA observed at least a three (3) day perishable and seven (7) days non-perishable foods, adequately stored. There are three (3) twenty-five (25)-day emergency food is stored nearby the entrance and in the garage cabinet there is ample bottled water in case of emergency. Dishwasher in kitchen properly installed and in functioning condition.
Smoke Detectors:
Smoke and Carbon monoxide detectors located in each room and are hard-wired. The alarm system has been professionally installed and have been tested during today's visit.
Appliances:
Stove burners, oven, two (2) microwaves, washer, and dryer are in working condition. There is one refrigerator, measured at, at least, 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat and each client bedroom is individually climate controlled.

Report continues, see LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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: HEALING HOME
FACILITY NUMBER: 198320547
VISIT DATE: 09/04/2025
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Toxins:
During today's visit, LPA observed all cleaning detergents were stored inaccessible to residents in care. There are no firearms located on the premises.
Water Temperature:
Water temperature was tested and remain within Title 22 regulations.
Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored under the kitchen island, available for staff use but inaccessible to clients.
Clients & Staff Files:
Records of staff and clients are stored in a locked cabinet underneath the kitchen island and are inaccessible to residents in care.
Reading Material, Games, Equipment & Materials:
The facility has board games, adult coloring books, painting easel and other recreational materials for the client's use, commensurate with the plan of operation.
Pool/Jacuzzi & Pets:
None present.
Fire clearance:
Fire Clearance was approved on 04/08/25 for 5 non-ambulatory and one (1) bedridden in bedroom number one #(1). All windows have appropriate release and there were no obstructions observed for a safe and quick egress during an emergency.
Prelicensing Component III:
During the prelicensing inspection, LPA presented component III and all staff present have acknowledged awareness.

An exit interview was conducted and a copy of this report has been furnished to the applicant. 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 their application.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
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