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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601570
Report Date: 09/05/2025
Date Signed: 09/08/2025 08:36:17 AM

Document Has Been Signed on 09/08/2025 08:36 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SENIOR LIVING LIFESTYLE- PALOS VERDESFACILITY NUMBER:
198601570
ADMINISTRATOR/
DIRECTOR:		ROBERT SMITHFACILITY TYPE:
740
ADDRESS:3832 PALOS VERDES DRIVE NORTHTELEPHONE:
(424) 241-2539
CITY:PALOS VERDES ESTATESSTATE: CAZIP CODE:
90274
CAPACITY: 6CENSUS: 4DATE:
09/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:26 AM
MET WITH:Robert SmithTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 09/05/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above. LPA met with Administrator, Robert Smith, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve six (6) residents aged 60 and up, five (5) of which may be non-ambulatory and one (1) bedridden, with an approved hospice waiver for four (4) residents.
Physical Plant/Structure The facility is a single-story structure located in a residential neighborhood. The facility consists of three (3) resident bedrooms, 2 bathrooms, living room, dining room, office area, kitchen, and attached garage. In the back is a patio with table and chairs available for resident use. LPA did not observe any bodies of water on the premises. There are no security bars on the windows.
Bedrooms LPA inspected the three (3) resident bedrooms and observed them to be clean and in good repair. LPA observed resident rooms have the required furniture, including beds, dresser, nightstand, chair, and storage space for resident’s personal belongings. LPA observed the resident beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of linens in good repair.
Bathroom LPA inspected the bathrooms and observed them to meet Title 22 regulations. LPA observed the bathrooms are clean and operational. LPA observed there are secured safety handrails in the showers. LPA observed an ample supply of towels and hand towels. LPA observed an ample supply of hygiene supplies. The water temperature measured 110.5-degrees and 111.8-degrees Fahrenheit. LPA observed cleaning supplies secured in a locked cabinet
Kitchen LPA observed the kitchen was clean and sanitary. LPA observed an ample supply of dishware, cookware, and cutlery. LPA observed a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. LPA observed knives and sharps secured in a locked cabinet. The water temperature measured 110.6-degrees Fahrenheit.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2025
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SENIOR LIVING LIFESTYLE- PALOS VERDES
FACILITY NUMBER: 198601570
VISIT DATE: 09/05/2025
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Common Areas LPA observed the living room has a couch and recliner to accommodate residents. LPA observed a fireplace screened and inaccessible to residents. LPA observed the dining room has a large table and chairs to accommodate residents. LPA observed games and activities available for residents’ use.
Medications LPA observed Centrally Stored Medications secured in a locked cabinet in the kitchen and are inaccessible to residents. LPA observed medications in their original packaging. LPA reviewed the medications and Medication Administration Record (MAR) for four (4) residents and observed four (4) out of four (4) resident medications are consistent with properly documented records.
Safety LPA observed smoke and carbon monoxide detectors are operable and in compliance. LPA observed a fully charged fire extinguisher, last serviced on 12/09/2024, mounted in the kitchen. The last emergency drill was conducted on 06/18/2025. LPA observed the First Aid kit is fully stocked and has the required items. LPA observed the required documents are posted throughout the facility. The facility has a working landline telephone. LPA observed cleaning supplies secured in a locked cabinet. No firearms or ammunition are stored at the facility.
File Review LPA reviewed the files for four (4) residents. LPA observed four (4) out of four (4) resident files contained the required documents. LPA reviewed the file for the administrator and one (1) staff. LPA observed staff have the required documents, training, and certification. The administrators Administrator Certificate is valid till 04/13/2026. LPA observed Licensing Fees are current.
Infection Control LPA observed the facility’s infection control practices. Upon entry LPA observed a Sign-In Log at the entrance and hand sanitizer. LPA observed Infection Control signs posted throughout the facility. LPA observed a 30-day supply of PPEs.

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Administrator, Robert Smith, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
LIC809 (FAS) - (06/04)
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