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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320614
Report Date: 07/23/2025
Date Signed: 07/23/2025 01:45:36 PM

Document Has Been Signed on 07/23/2025 01:45 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:SENIOR HEARTS VILLAFACILITY NUMBER:
198320614
ADMINISTRATOR/
DIRECTOR:		SOMODIO, LAUREANA B.FACILITY TYPE:
740
ADDRESS:1729 MANUEL AVENUETELEPHONE:
(424) 731-6332
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 0DATE:
07/23/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:49 AM
MET WITH:Laureana SomodioTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA), Regina Cloyd, conducted an announced visit to the facility for purpose of a prelicensing evaluation. An application was submitted to CCLD for initial license for a Residential Care Facility for the Elderly to serve the Elderly for 60 years and older. The requested capacity is for six (6) non-ambulatory. The facility has a fire clearance with the following special conditions: The rooms are approved for non-ambulatory/bedridden and approved for delayed egress or delayed egress with secured (locked) perimeter as of 06/18/2025. Fire alarm is required and the smoke detectors must be interconnected.

Structure:
Facility is a four (4) bedroom, two (2) bathroom, single story house. There is a large backyard and attached garage.
Bedrooms Residents:
Bedrooms #1 - 3 are for non-ambulatory residents. Bedroom #2 has two beds, one chair, one dresser, a closet and overhead lighting. Bedrooms #1 and #3 have one queen sized bed, one chair, adequate closet space, and overhead lighting. Bedroom #4 will be used by staff. Continue to LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2025
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: SENIOR HEARTS VILLA
FACILITY NUMBER: 198320614
VISIT DATE: 07/23/2025
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Bathrooms:
Both bathrooms have a working toilet, wash basin, and step-in shower. Bathrooms will accommodate non-ambulatory residents in a wheelchair.
Linens & Hygiene Supplies:
Bedroom #2 has the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Additional linen is stored in the closet near bedroom #1.
Emergency Phone Numbers, Exit Plan & Menu:
There is a fire extinguisher located in the kitchen, garage and hallway near bedrooms #1 - 3.
Food Service:
Dishes, cups and flatware are stored in the kitchen cupboards, inspected and in good repair. Food supply adequately stored in the cabinets and refrigerator and consists of the following: canned goods, fruit, meat, and vegetables.
Smoke Detectors & Carbon Monoxide Detector:
Interconnected smoke detectors and one carbon monoxide near the kitchen pantry.
Appliances:
Stove burners, oven, microwave, washer, and dryer are working. There is one large refrigerator and small refrigerator for drinks in the kitchen. Each refrigerator has a measured temperature of at least 40 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is not equipped with central air and heat.
Toxins:
Locked/stored.
Continue to LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
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: SENIOR HEARTS VILLA
FACILITY NUMBER: 198320614
VISIT DATE: 07/23/2025
NARRATIVE
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Water Temperature:
Tested at 127 degrees.
Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, and gauze, which are stored in the kitchen cabinet, available for staff use but inaccessible to residents.
Reading Material, Games, Equipment & Materials:
The facility has board games, reading materials, cards and puzzles for the residents' use. Pool/Jacuzzi & Pets:
None.

PRE-LICENSING CHECKLIST
Not completed by the Licensee.

COMPONENT III
Information was provided about how to operate the facility within substantial compliance. During the prelicensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA Regina Cloyd (regina.cloyd@dss.ca.gov) by 08/12/2025. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

Continue to LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
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: SENIOR HEARTS VILLA
FACILITY NUMBER: 198320614
VISIT DATE: 07/23/2025
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1. The licensee shall have and maintain a current, written definitive plan of operation for the facility. The plan and related materials shall be on file in the facility.

2. Licensee shall prominently post facility’s policy regarding theft and investigative procedures, personal rights, additional personal rights of residents in privately operated facilities, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public.

3. The facility shall be clean, safe, sanitary and in good repair at all times.

4. Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

5. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

6. Slip-resistant mats, strips, or flooring shall be used in all bathtubs and showers floors.

7. A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary.

Continue to LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
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: SENIOR HEARTS VILLA
FACILITY NUMBER: 198320614
VISIT DATE: 07/23/2025
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8. Bedroom furniture, which shall include, for each resident, a chair, nightstand, a lamp, or lights sufficient for reading, and a chest of drawers.

9. All outdoor and indoor passageways and stairways shall be kept free of obstruction.

10. All facilities shall have telephone service on the premises.

11. The Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

12. A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

13. A set of keys available to facility staff on each shift for use during an evacuation that provides access to all of the following: (C) All facility exit doors.

14. Plan for evacuation including: (A) Fire safety plan.

An exit interview was conducted, and a hard 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: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
LIC809 (FAS) - (06/04)
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