198320622-1-14-2026-11-AS-MLEN-DQBQBB-20260114110115

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320622
Report Date: 01/14/2026
Date Signed: 01/14/2026 11:01:28 AM

Document Has Been Signed on 01/14/2026 11:01 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:	PV LIVING, LLC		FACILITY NUMBER:	198320622
ADMINISTRATOR/ DIRECTOR:	FAJARDO, MIGUELITO		FACILITY TYPE:	740
ADDRESS:	1922 VELEZ DRIVE		TELEPHONE:	(323) 345-1730
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:	09:21 AM
MET WITH:	Tina Cinco		TIME VISIT/ INSPECTION COMPLETED:	11:07 AM

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 an unannounced post-licensing visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. LPA was met by staff two, Bernadeth Salvador - Caregiver (S2) and later by staff one, Tina Cinco - Administrator (S1) and the purpose of today's visit was explained. LPA verified that the facility has an approved mitigation plan report and infection control plan. There are currently 3 Residential Care Facility for the Elderly (RCFE) residents in placement. The facility's annual fees are up to date. LPA and S1 toured the facility, 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, kitchen and an attached garage that will be used for storage and extra food items. LPA observed sufficient liquid soap, paper goods, cleaning, and disinfecting supplies. Documents are posted in the facility hallway on the bulletin board. The following Title 22 regulated areas were audited and found to be in compliance: The facility telephones are working. Bedrooms: All bedrooms meet the required standards for furniture, safety, privacy, and comfort. The facility has an adequate linen supply. Bathrooms: The bathrooms are clean and operational, and provide necessary personal accommodations with non-skid surface mats ensuring safety and privacy. Kitchen and Food Service: The kitchen is adequately equipped for food preparation and service. A review of the food service revealed an ample supply of perishable and nonperishable food, stored appropriately. Medication Storage and Management: Medications are centrally stored in a locked cabinet in the hallway with up-to-date records, ensuring proper storage and documentation. 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: PV LIVING, LLC	FACILITY NUMBER: 198320622
	VISIT DATE: 01/14/2026

NARRATIVE

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Common Areas: The Living room, dining room, and common areas are well maintained, free of potential hazards, and meet the cleanliness standards necessary for the safety and well-being of residents. Safety Equipment and Measures: The facility is equipped with a fully stocked first aid kit with manual, functional smoke and carbon monoxide detectors, and properly charged fire extinguishers. The hot water temperature is measured at degrees and is maintained within the standard range of 105-120 degrees Fahrenheit. Emergency Preparedness: All exit doors are in compliance, the client's bedroom windows are equipped with sliding window locks without thumbscrews. Environmental Safety: The yard is free from debris and hazards, trash cans are covered, and no firearms or bodies of water are present on the premises. Hazardous items are kept inaccessible to clients. Staff Training: Staff members have received training on reporting dependent adult and elder abuse and Cardiopulmonary . Administrative Compliance: The Administrator has successfully completed the required training. The Administrator Certificate is current and expires on 06/26/27.

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

An exit interview was held with Tina Cinco - Administrator (S1) 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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