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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602982
Report Date: 10/22/2025
Date Signed: 10/22/2025 04:49:04 PM

Document Has Been Signed on 10/22/2025 04:49 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:FAMILY CONNECTED MEMORY CARE BOUTIQUEFACILITY NUMBER:
198602982
ADMINISTRATOR/
DIRECTOR:		SPIGLANIN, LAURENFACILITY TYPE:
740
ADDRESS:3414 WEST 226TH STREETTELEPHONE:
(310) 383-1877
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 5CENSUS: 5DATE:
10/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:38 PM
MET WITH:Kristi SimonianTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 10/22/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above. LPA met with Administrator, Kristi Simonian, and the purpose of today’s visit was explained. The facility is licensed to operate for five (5) elderly residents aged 60 and above. The facility is approved for five (5) non- ambulatory residents with an approved hospice waiver for two (2). There are five (5) residents residing in the facility and all five (5) residents were present during the visit.

Physical Plant/Structure The facility is a single-story structure located in a residential neighborhood. The facility consists of three (3) resident rooms, two (2) bathrooms, living room, dining room, kitchen, office area, and an attached garage. The ramps leading to the front and back door have secured railings. LPA observed a table with umbrella and chairs on a patio in the back yard. All walkways were observed clean, clear, and free of obstructions, hazards, and debris. LPA did not observe any bodies of water on the premises.

Bedrooms LPA inspected all bedrooms and found them to be clean and in good repair. All rooms were observed with the required furniture including a bed, dresser, nightstand, chair, and adequate storage space for resident’s personal belongings. All beds were observed with the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. Beds and bedding supplies were observed in good repair. All bedrooms were observed with adequate lighting. LPA observed an adequate supply of linens stored in a hall closet.

Bathrooms LPA observed the bathrooms to be within Tittle 22 regulations and fully operable. The showers had secured safety handrails, nonskid mats, and shower chairs. The water temperature measured 107.1-degrees Fahrenheit. LPA observed an adequate supply of bath towels and wash clothes stored in a hall closest in good repair. LPA observed storage space for resident’s hygiene products. An additional supply was observed stored in the garage and are inaccessible to residents.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2025
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: FAMILY CONNECTED MEMORY CARE BOUTIQUE
FACILITY NUMBER: 198602982
VISIT DATE: 10/22/2025
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Kitchen The kitchen was inspected and observed to be clean and sanitary. LPA observed all appliances to be operational and in good repair. LPA observed an ample supply of dishware, cookware, and cutlery in
good repair. LPA observed knives and sharps secured in a locked cabinet in the kitchen and are inaccessible to residents. All cleaning supplies were observed secured in a locked cabinet under the kitchen sink and are inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of non-perishable foods properly stored and labeled. The water temperature measured 115.5-degrees Fahrenheit.
Common Rooms LPA toured all rooms in the home. LPA observed the facility to be furnished appropriately to accommodate all residents. The living room had chairs to accommodate all residents. The dining room has a large circular table to accommodate all residents. LPA observed games, activities, puzzles and reading material available for residents. The facility was maintained at a comfortable temperature. All rooms were observed with ample lighting. All walkways were observed to be clean, clear, and free of obstructions and hazards.
Safety LPA observed all required signs posted throughout the facility. LPA observed two (2) fully charged fire extinguishers last serviced on 11/18/24, one in the dining room area and the other in the office area. The last Fire Prevention Inspection from the Torrance Fire Department was conducted on 03/29/2024. LPA observed the Emergency Disaster Plan posted in the entrance of the facility and was last updated on 01/01/2025. First aid kit was fully stocked with necessary supply and a manual. Smoke/carbon monoxide detectors were operable. The last fire drill was on 09/08/25. LPA observed the facility has a working landline.
File Review The department reviewed three (3) staff files and observed they had the required documentation, training, and certification. The administrator’s Administrator Certificate, 7011850740, is valid till 11/21/26. LPA did look and see that the renewal is pending, and observed the documents submitted. The department reviewed the files for five (5) residents and found they contained the required documents and current assessments. The facility has liability insurance through Accord that is valid till 02/19/2026. During facility file review, LPA observed licensing fees are current.
Medications LPA observed all Centrally Stored Medication secured in a locked cabinet in the office area. All medications were observed in their original packaging. LPA reviewed the medications and medication administration record (MAR) for five (5) residents and found they were consistent with properly documented records.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: FAMILY CONNECTED MEMORY CARE BOUTIQUE
FACILITY NUMBER: 198602982
VISIT DATE: 10/22/2025
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Infection Control During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed required infection control signs posted throughout the facility. LPA observed a 90-day supply of PPEs stored in the garage.

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Administrator, Kristi Simomian, 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: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC809 (FAS) - (06/04)
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