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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320579
Report Date: 09/18/2025
Date Signed: 09/18/2025 10:42:28 AM

Document Has Been Signed on 09/18/2025 10:42 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:COLLABORATIVE RCFEFACILITY NUMBER:
198320579
ADMINISTRATOR/
DIRECTOR:		BAH, BRIDGETFACILITY TYPE:
740
ADDRESS:1814 W. 84TH STREETTELEPHONE:
(323) 531-2001
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 4CENSUS: 0DATE:
09/18/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Bridget Bah/LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On 9/18/25 Licensing Program Analysts (LPA) Alfonso Iniguez conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with Bridget Bah/License.

The licensee has applied for a license to serve (4) elderly residents ages 59 and older. The fire clearance is approved for (4) non-ambulatory only.

The facility is located on a residential neighborhood, it consists of (4) bedrooms, (1 1/2) bathroom, living room, dining room, kitchen, front porch with shaded area and back yard with shaded area, and closet areas.

The following was observed during this visit:

MEDICATIONS

There is a locked centralized storage area for Resident medications.

PHYSICAL PLANT

The facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. The facility temperature is between 68 degrees and 85 degrees. Open porches, and areas of potential hazard are well-lit and equipped with sturdy hand railings. Smoke alarms operate properly. Carbon monoxide detectors operate properly.

Pre-licensing report continues next page LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Alfonso Iniguez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: COLLABORATIVE RCFE
FACILITY NUMBER: 198320579
VISIT DATE: 09/18/2025
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BEDROOMS

No client bedroom is a passageway to another room, bath or toilet. There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair.

Mattresses and pillows are flame-retardant. There is a dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client.

BATHROOMS

There is at least one (1) toilet and washbasin per six (6) clients, family, and personnel. There is at least one (1) shower or bathtub per ten (10) clients, family, and personnel. The bathrooms are located near client bedrooms.

SUPPLIES

-Missing

FOOD SERVICE

The dining room is near the kitchen. Refrigerator(s) and freezer(s) are clean and large enough for storage. The freezer is 0 degrees Fahrenheit. Refrigerator is a maximum of 45 degrees Fahrenheit.

RECORDS

There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility.

Pre-licensing report continues next page LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Alfonso Iniguez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
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: COLLABORATIVE RCFE
FACILITY NUMBER: 198320579
VISIT DATE: 09/18/2025
NARRATIVE
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ADMINISTRATION

-Missing

ACTIVITIES

There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors.

MISCELLANEOUS

There are first-aid supplies to 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.

During the pre-licensing inspection, LPA Iniguez found corrections are needed. The following items must be corrected:

Observations:

-Water temperature measure 131 F.

-Missing Chairs in all residents’ bedrooms.

-Missing nightlights present in hallways.

-Missing hygiene items.

-Missing clean linens (blankets, bedspreads, top sheets, bottom sheets, pillowcases, mattress pads, bath towels, hand towels and wash cloths).

-Missing (7) day supply of non-perishable food for (4) people.

Pre-licensing report continues next page LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Alfonso Iniguez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
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: COLLABORATIVE RCFE
FACILITY NUMBER: 198320579
VISIT DATE: 09/18/2025
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-Missing (2) day supply perishable food for (4) people.

-Missing tableware, tables, dishes, and utensils.

-Missing emergency exit plans and telephone numbers are posted.

-Missing facility theft and loss program.

-Missing Residents Rights.

-Missing complaint poster.

-Missing resident counsel rights.

-Missing laundry supplies.

-Missing emergency lighting supplies.

Proof of correction should be ready before scheduling the next pre-licensing visit. LPA Iniguez provided a copy of pre-licensing check items to the licensee.

A copy of this report was given to Bridget Bah/Licensee.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Alfonso Iniguez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC809 (FAS) - (06/04)
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