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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320550
Report Date: 04/07/2025
Date Signed: 04/07/2025 11:50:27 AM

Document Has Been Signed on 04/07/2025 11:50 AM - 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:HOME OF THE AMAZINGFACILITY NUMBER:
198320550
ADMINISTRATOR/
DIRECTOR:		CARBAJAL, ANDREAFACILITY TYPE:
740
ADDRESS:28819 GUNTER RDTELEPHONE:
(310) 906-7399
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 0DATE:
04/07/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:33 AM
MET WITH:Andrea CarbajalTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
NARRATIVE
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On April 7, 2025 Licensing Program Analyst (LPA), Deborah Lee conducted an announced visit to the facility for the purpose of conducting a pre-licensing evaluation. An application was submitted to CCLD on October 22, 2024, for opening a new facility for an Adult Residential Care Facility for the Elderly (RCFE) to serve 5 non-ambulatory residents; 1 could be bed ridden. Fire clearance approved on February 26, 2024. LPA met Andrea Carbajal applicant, and explained that the purpose of today’s visit. LPA and Applicant toured the physical plant(inside and outside).

Overview of Facility:

Facility is a single-story home located in a residential neighborhood. Entry way of the home is clear and free of debris and obstruction. There is a separate resident entrance on side of home that is accessible to the home. LPA observed a sanitation station and visitor sign-in as you enter the facility. There are 5 resident bedrooms, 3 bathrooms, dining room, living room, laundry room, and attached garage that will be used for storage and extra food items. The Resdients' bedrooms are spacious and can easily accommodate the client's furnishings.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2025
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: HOME OF THE AMAZING
FACILITY NUMBER: 198320550
VISIT DATE: 04/07/2025
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** Amended to obtain signatures

LPA observed that there are no bodies of water on the premises. The shaded area and outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPAs did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms Residents: Bedrooms 1-5 have working lights, new blinds and working windows with no bars. 4 bedroom will be private rooms/occupied by 1 resident and 1 shared occupied by 2 client. Bathrooms: All Bathrooms have a working toilet, wash basins and shower, and observed to be clean, safe, and sanitary. LPAs observed adequate lighting throughout the entire facility. Linens & Hygiene Supplies: Extra linens are in linen closes located in hallway next to bathroom #1.

Living room The Living room is fully furnished with sofa, 2 recliners, TV, lamp, covered fire place. The dining area is equipped with 6 seated dinning set, cabinet and printer. Facility has a lanline phone for emergencies. There is 1 fully charged fire Extinguishers located in the kitchen area. LPA observed all required postings: See something say something, clients rights, activity schedule, emergency disaster plan, facility sketch menu (posted on refrigerator).

Smoke Detectors: Facility has 7 smoke detectors/carbon monoxide detectors are hardwired and interconnected. They were tested and operable. Appliances: LPA observed all kitchen appliances and washer and dryer in working order. LPA observed a 7 day supply of non-perishables and 2 day supply of perishable food items. The residence is equipped with heat and air conditioning. Toxins: Applicant showed LPA, where toxins to be locked/stored. Water Temperature: tested at 109 degrees F. Residents & Staff Files: Resident and staff files will all be stored in locked cabinet located in the dining area.

There are no corrections needed.

Component III: Conducted during today’s Pre-Licensing visit

A copy of this reported provided to Andrea Carbajal, Applicant.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC809 (FAS) - (06/04)
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