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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320472
Report Date: 09/11/2026
Date Signed: 09/11/2026 03:02:05 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/11/2026 03:02 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:VILLA MARCOSAFACILITY NUMBER:
198320472
ADMINISTRATOR/
DIRECTOR:		MATUTE, ROSITA FFACILITY TYPE:
740
ADDRESS:1135 E AMELIA DRIVETELEPHONE:
(562) 257-0563
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 6CENSUS: 5DATE:
09/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:43 AM
MET WITH:Rosita Matute - Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:19 PM
NARRATIVE
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On 09/11/26, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced 1-Year Required Annual Visit using the CARE Inspection Tool. Due to technical difficulties, LPA unable to generate an electronic CARE inspection tool and instead used a printable/PDF version. California Department of Social Services (CDSS) was met by Rosita Matute, Administrator, and the purpose of today’s visit was explained. This facility is licensed to serve 6 non-ambulatory residence over 60 years old. A total of five (5) residents are currently residing in this facility. Facility has a hospice waiver for 6.
The facility is a single-story home located in a residential neighborhood. The home has dual entry doors that open into a foyer. There are five (5) resident bedrooms, three and a half (3 1/2) bathrooms, dining room, living room, laundry room off of kitchen area. There is an attached garage, with a deep-freeze unit. The facility has a pool that is gated with required locking on the gate, inaccessible to residents in care.
CDSS inspected all 5 bedrooms; the mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Toilets and water faucets worked properly, grab bars were secure, with non-skid mats in place. Adequate lighting and toiletries are accessible to residents. CDSS tested hot water temperature and it measured within title 22 regulation, at 108.6°F (degrees Fahrenheit). This facility provides residents with hygiene products such as non-medicated soap, toilet paper, toothbrush, toothpaste shampoos, lotions. The living room is fully furnished with sofa, 2 chairs, coffee table, 3 recliners and mounted TV. There is adequate space for activities and there are adequate activity supplies in place. CDSS observed all required documents posted throughout the facility. The facility has a working land line telephone.
Report continues, please see LIC809-C.
Ulysses Coronel
Mario Leon
DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2026
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: VILLA MARCOSA
FACILITY NUMBER: 198320472
VISIT DATE: 09/11/2026
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CDSS inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, dishwasher, refrigerator. LPA observed an ample supply of cutlery, pots, pans, and bowls, all in good repair. CDSS observed knives and additional sharps secured in garage area, inaccessible to residents in care. CDSS observed 2-day supply of perishable foods and 7-day supply of non-perishable foods properly stored, packaged, and labeled. First aid kit is fully stocked with all required items.
CDSS observed two (2) fully charged fire extinguishers, last serviced on 7/3/24. According to Title 22 regulation 87203, "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.", which states that an extinguisher "must be serviced and tagged annually by a licensed professional". One deficiency has been cited, please see LIC809-D.
The last emergency drill was conducted on 7/11/26. Smoke/Carbon Monoxide detectors were tested and operable, all interconnected.
LPA reviewed five (5) resident files and found that 5 out of 5 resident folders have the required documents. LPA reviewed three (3) staff files and found that 3 out 3 had all required documents, training, and certifications.
LPA reviewed a copy of the facility’s Liability Insurance with expiration date of 9/25/26.
LPA observed all centrally stored medications secured All medications were observed in their original packaging. The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites, last updated on 04/26 (dated April 2026).

Facilities' Administrator, certificate number 7006130740, is valid through 10/15/2026.

During today’s visit there has been one (1) deficiency cited.

An exit interview was conducted with Rosita Matute - Licensee/Administrator and a copy of one (1) deficiency, this report, and facilities' appeal rights have been provided.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2026 03:02 PM - It Cannot Be Edited


Created By: Mario Leon On 09/11/2026 at 02:50 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: VILLA MARCOSA
FACILITY NUMBER: 198320472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2026
Section Cited
CCR
87203

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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 LPA observation, which poses a potential health
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LPA and Licensee have agreed that the facility will have their fire inspector come to perform the annual maintenance inspection of two (2) fire extinguishers on, or prior to, the POC due date.
Licensee will forward photographs of the annual maintenance having been performed,
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risk to residents in care.
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via email, at MARIO.LEON@DSS.CA.GOV

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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.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Mario Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
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