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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602226
Report Date: 10/04/2025
Date Signed: 10/04/2025 04:34:32 PM

Document Has Been Signed on 10/04/2025 04:34 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:PVE MANORFACILITY NUMBER:
198602226
ADMINISTRATOR/
DIRECTOR:		JEHN MARIC DEMAFELIXFACILITY TYPE:
740
ADDRESS:3916 PALOS VERDES DRIVE NORTHTELEPHONE:
(310) 375-8996
CITY:PALOS VERDES ESTATESSTATE: CAZIP CODE:
90274
CAPACITY: 6CENSUS: 5DATE:
10/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Lyann YuTIME VISIT/
INSPECTION COMPLETED:
12:31 PM
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On October 4, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with caregiver Lyann Yu. Yu contacted the administrator and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory of which (1) maybe bedridden elderly residents ages 60 and above. The facility is approved for (3) hospice residents. Currently, the facility has (3) residents in hospice care.

The facility is a single-story home consisting of: (6) resident bedrooms, (3) Full bathrooms, (1) staff bedroom, living room, kitchen, dining room, laundry room (located in the attached garage), garage and an outdoor shaded patio area.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 105.1 F. A comfortable temperature of 69.0 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable.
(Evaluation Report continues LIC 809-C)
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2025
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: PVE MANOR
FACILITY NUMBER: 198602226
VISIT DATE: 10/04/2025
NARRATIVE
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 A review of the Medication Administration Record (MAR) was complete and accurate. The facility has conducted a disaster drill on 09/15/25. A landline telephone was in working condition.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted.

LPA observed First Aid Kit along with an American Red Cross First Aid Manual was maintained. The facility is current on Community Care Licensing annual dues. The facility has a current liability insurance with policy # 00123055-3 effective 10/15/24 through 10/15/25.

An audit of residents #1-#5 (R1-R5) service files and staff #1-#6 (S1-S6) personnel files were in order and complete. The facility has the current administrator's certification on file for Jehn Maric Demafelix Administrator's Certificate #7021644740 effective 01/30/24 through 01/30/26.

Deficiencies:
  • At 11:50 AM LPA identified smoke detector for Resident #3's bedroom non-operational.
  • Staff #1 through Staff #6 all did not have current CPR/First Aid Certificate on file.
  • Resident #3 did not have TB test results on file.

An exit interview was conducted with Lyann Yu , and a copy of the report was provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/04/2025 04:34 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/04/2025 at 11:18 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PVE MANOR
FACILITY NUMBER: 198602226

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA identified smoke detector for Resident #3 room non operable. This violaton which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2025
Plan of Correction
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Licensee w/ill ensure that facility is in good repair at all times. Licensee will ensure to repair or replace smoke detector in Resident #3's room with an operable smoke detector. POC is due 10/06/25 to ernand.dabuet@dss.ca.gov

Note: Corrected during visit on 10/04/25 at 12:03PM
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/04/2025 04:34 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/04/2025 at 12:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PVE MANOR
FACILITY NUMBER: 198602226

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(1)(A)
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified on TB results for Resident #3 on file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2025
Plan of Correction
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Licensee will ensure prior to resident's admittance, all must TB test completed. Licensee will ensure obtain TB test for Resident #3 by POC 10/18/25 and submit proof to ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General - All RCFE staff...shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above. LPA identified staff #1 through staff #6 all did not a valid or current CPR/First Aid on file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2025
Plan of Correction
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Licensee is to obtain current first aid certificates for all staff # 1 through #6 and will create a plan to ensure that ensure that caregiver staff who assist residents with personal activities of daily living receive annual first aid training. Proof of correction will be submitted to CCL via email at ernand.dabuet@dss.ca.gov.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2025


LIC809 (FAS) - (06/04)
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