Palos Verdes Care Cottage

Type of visit: Required - 1 Year

On 10/31/25 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced required – annual inspection and was met by staff one, Salvacion Medina - Administrator (S1). The facility is licensed to serve six (6) ambulatory residents, of which four (4) may be non-ambulatory and one (1) may be bedridden. Bedroom #1 is approved for ambulatory. Bedroom #2 and #4 are approved for non-ambulatory. Bedroom #3 is approved for bedridden and non-ambulatory. The facility has a hospice waiver approved for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of (4) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room and a attached garage. Staff one (S1) accompanied LPA inside and outside the facility during today's inspection. Resident bedrooms had the required furniture, bed linens, and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew, and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked during today's visit. All water sources presented water temperature within title 22 regulation LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. Staff tested the carbon monoxide detector and smoke detectors in the house. All devices were functional. Five (5) resident records and two (2) staff records were reviewed. No discrepancies were observed. There have been zero deficiencies cited during today's visit. An exit interview was held with S1 and a copy of this report have been provided.the state’s words, verbatim · CDSS document, Oct 31, 2025

Allegation investigated: Staff do not ensure the facility's smoke and other detectors are properly operating Staff do not ensure passageways are free from obstruction

On 06/06/25 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. LPA was met by staff two, Tri Kristianingsih Caregiver (S2), and later by staff one, Ma Salvacion "Salve" Medina (S1) Administrator, and the purpose of the visit was explained. S1 and LPA toured the facility. The investigation consisted of the following: On 6/06/25 LPA requested documents, including the resident roster (dated: 06/06/25) and staff roster (dated: 09/01/24), Earthquake/fire emergency drills (last conducted 06/03/25), Emergency and Disaster Plan (LIC610E) (last updated: 04/25/25) and LPA toured the facility. LPA interviewed one (1) out of three (3) residents (R1), one (1) witness (W1) and two (2) out of five (5) staff (S1-S2). Resident two and Resident three (R2-R3) were not able to be interviewed due to their medical condition. Report continues, see LIC9099-C. Substantiated The investigation revealed the following: Regarding the allegation “Staff do not ensure the facility's smoke and other detectors are properly operating”, it is being alleged that the facility’s emergency alert system is in disrepair. During today’s inspection, LPA observed seven (7) smoke/carbon monoxide detectors. LPA observed that three (3) out of seven (7) smoke detectors in the house were in disrepair. From 10:00AM to 11:10AM, LPA interviewed R1, W1, and S1-S2. Interviews revealed the following: S1 and S2 have denied the allegation has taken place, while W1 agreed to have never observed staff testing the smoke alarms. Based on LPA's observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited. Please see LIC9099-D. Regarding the allegation “Staff do not ensure passageways are free from obstruction”, it is being alleged that the outdoor walkways of the facility are obstructed. During today's inspection, LPA observed two (2) outdoor walkways. From 10:00AM to 11:10AM, LPA interviewed R1, W1, and S1-S2. Interviews revealed the following: R1, W1, S1 and S2 have denied the allegation has taken place. S1 has confirmed the Eastern walkway as the main exit. Although nobody interviewed has confirmed the allegation has taken place, LPA's observed one (1) out of two (2) outdoor walkways as being obstructed. Based on LPA's observation, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited. Please see LIC9099-D. There have been two (2) deficiencies cited during today's inspection, please see LIC9099-D. An exit interview was held with staff one, Ma Salvacion "Salve" Medina (S1), and a copy of the facilities' appeal rights, two (2) deficiencies, and this report have been provided. The investigation revealed the following: Regarding the allegation “Staff do not ensure the facility is in good repair”, it is being alleged that the facilities’ aluminum wiring is in disrepair which has resulted in a melted electrical outlet. From 10:00AM to 11:10AM, LPA interviewed R1, W1 and S1-S2. Interviews revealed the following: R1, W1 and S2 have denied the allegation has taken place, while S1 has confirmed that on Tuesday, 06/03/25, maintenance staff have come to replace the outlet due to disrepair, which indicates the facility wishes to provide safe, healthful and comfortable accommodations, furnishings and equipment to residents in care. During today’s inspection, LPA did not observe any of the facilities' lights dimming nor any other electrical concerns and LPA tested the working outlet which charged LPA's laptop computer. Based on LPA's observation and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding this allegation, there have been zero (0) deficiencies cited. An exit interview was held with staff one, Ma Salvacion "Salve" Medina (S1), and a copy of the facilities' appeal rights, two (2) deficiencies, and this report have been provided.the state’s words, verbatim · CDSS document, Jun 6, 2025 · control 11-AS-20250604095253

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87203 · Plan of correction due date: Jun 6, 2025

87203 - Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This has not been met as evidenced by: Based on LPA's observation the licensee did not ensure the facility remains within the regulations adopted by the State Fire Marshal in rooms 1, 2, 3 to ensure that control equipment produces an alarm signal, and are in working condition, to protect life and property, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jun 6, 2025

Plan of correction: The licensee and LPA have agreed that the facility will ensure that rooms 1, 2 and 3 are able to produce an alarm from the control equiptment observed in disrepair. During today's visit, S1 repaired rooms 1, 2 and 3 control equiptment. LPA has provided POC letter to S1.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Jun 6, 2025

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This has not been met as evidenced by: Based on LPA's observation, the licensee did not ensure that the facilities' Eastern walkway remains free of obstruction, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jun 6, 2025

Plan of correction: The licensee and LPA have agreed that the facility will ensure that all emergency exits will remain free of obstruction. During today's visit, S1 has cleared the Eastern outdoor walkway. LPA has provided POC letter to S1.

Type of visit: Case Management - Annual Continuation

On 11/02/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced annual continuation inspection and met with Staff Tri Kristianingsih. LPA explained the purpose of the visit and spoke with the Administrator Ma Salvacion Medina over the phone. The purpose of today's visit is to deliver deficiencies observed on 10/12/2024. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8 (See LIC809-D pages). On 10/12/24, LPA did not observe a operable washer and dryer. Administrator stated that it has been out since 10/11/24. On 10/12/24, LPA observed an outdoor medical equipment and grill blocking one resident outdoor exit. LPA also observed a resident's couch blocking another resident's outdoor exit. LPA observed material (buckets, bags, rug, equipment, laundry baskets, trash cans, and etc) around the perimeter of the house. Continue to LIC809-C. On 10/12/2024, the Administrator was not present and staff had a challenging time locating facility records, resident records, and staff records. LPA and staff had to communicate with Administrator over the phone and still faced challenges. Also, during record and medication review, Resident #2 needed two staff members. Two residents remained unsupervised in the living room and the tv program was turned off for about 60 - 90 minutes. On 10/12/2024, LPA observed a pill box sorter in the medication cabinet for Resident #2. On 10/12/2024 1:16 PM, LPA smelled feces in the facility until LPA's 5:00 PM departure. An exit interview was conducted, technical assistance provided, plans of correction developed, and a copy of this report with appeal rights was discussed with the Administrator Ma Salvacion Medina over the phone. Hard copies were provided to Staff Tri Kristianingsih.the state’s words, verbatim · CDSS document, Nov 2, 2024

Type of visit: Required - 1 Year

On 10/12/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff Robert Lim. LPA spoke with the Administrator Ma Salvacion Medina over the phone. The facility is licensed to serve six (6) ambulatory residents, all of which four (4) may be non-ambulatory and one (1) may be bedridden. Bedroom #1 is approved for ambulatory. Bedroom #2 and #4 are approved for non-ambulatory. Bedroom #3 is approved for bedridden and non-ambulatory. The facility has a hospice waiver approved for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It has a ramp that goes along the west side of the facility. It consists of (4) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room and a attached garage. Staff accompanied LPA inside and outside the facility during this inspection. Resident bedrooms had the required furniture, bed linens, and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew, and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Continue to LIC809-C. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. Staff tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional. Three (3) staff records were reviewed. Four resident records were reviewed and two residents’ medication was reviewed. Deficiencies were observed during today’s visit but due to insufficient time, an annual continuation is required. An exit interview was conducted and a copy of this report was discussed with the Administrator over the phone and left with Staff Robert Lim.the state’s words, verbatim · CDSS document, Oct 12, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced Annual required visit and an infection control inspection to the above facility. LPA was met by Ma Salvacion Administrator the purpose of today’s visit was explained. There are currently (4) residents in the facility. (1) residents are ambulatory and (2) are non-ambulatory (1) bedbound. The facility is a single-story structure located in a residential neighborhood. It has a ramp that goes along the west side of the facility. It consists of (4) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room and a attached garage. LPA and Care giver toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. INFECTIOUS CONTROL PRACTICES - LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked sanitizer/soap and paper towels in all the bathrooms and additional sanitation supplies are stored in hall closet and garage. LPA observed staff wearing masks, Residents private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Infectious Control Plan posted and/or in folder, Emergency infectious Plan posted and/or in folder, and required postings throughout the facility. Visitor designated area, resident temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPEs are enough for 30 days. All resident's and staff are vaccinated and boosted excepted one resident refused. OPERATIONAL REQUIREMENT - Fire clearances are incompliance. PHYSICAL PLANT ENVIRONMENTAL SAFETY - Bedrooms are occupied by residents and contain the mandated furniture. One staff bedroom. Bathrooms have nonskid mats, bars, and are clean and operational. (2) fire extinguishers are fully charged. First Aid kit complete with manual. The water temperature is at 115 degrees Fahrenheit. Linens and personal hygiene supplies are adequate. A comfortable temperature is maintained in the facility. Smoke detectors and carbon monoxide detectors are complying and operational. hazardous toxins and/or items are inaccessible to residents. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Due to time constraints, LPA could complete the annual inspection and all domains. LPA will return later to complete the rest of annual inspection and domains. Exit, walkways and/or passageways, front yard and back yard are free of debris and/or hazards. The facility is in good repair. STAFFING AND PERSONNEL RECORD TRAINING - 4 staff files are current with valid CPR cards, egress system operational, no volunteers at the facility. RESIDENTS REC - INCIDENT REPORT- 4 Resident files are current along with medications. RESIDENT'S RIGHTS - Internet access along with computer, visitor policy posted, PUB 475 posted. PLANNED ACTIVITIES - shaded area, indoor and outdoor activity area. FOOD SERVICE - Ample supply of perishable and nonperishable food and menu posted. INCIDENTAL M&D – The MARS is updated and complete. Resident’s medications are being given as prescribed by their physician. DISASTER PREPAREDNESS – The facility has an emergency and disaster plan, staff knows were shut off valves are located, flashlights available along with batteries, cell phones, additional emergency provisions, and conducted fire drill in April 2023. RESIDENT'S W/SHN - Some residents within facility require use oxygen and have sign posted. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this timethe state’s words, verbatim · CDSS document, Oct 4, 2023