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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601570
Report Date: 10/05/2026
Date Signed: 10/05/2026 12:45:04 PM

Document Has Been Signed on 10/05/2026 12:45 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: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: 2DATE:
10/05/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Evelyn SarmientoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 10/05/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit to the facility listed above. LPA met with care staff, Evelyn Sarmiento, and the purpose of the visit was discussed. LPA was granted entry into the facility. Administrator, Robert Smith joined LPA for the visit shortly after. The facility is licensed to serve six (6) residents aged 60 and up, of which five (5) may be non-ambulatory and one (1) bedridden, with an approved hospice waiver for four (4) residents. There are currently two (2) residents in the home.

The facility is a single-story structure located in a residential neighborhood. The facility consists of three (3) bedrooms, two (2) bathrooms, living room, dining room, office area, kitchen, and an attached garage. LPA observed a table and chairs available for resident use in the back patio. No bodies of water were observed on the premises. There are no security bars on the windows.

LPA conducted a tour of the facility. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of debris or hazards. Common areas were clean and clear of hazards and doorways were free of obstructions. LPA observed the facility clean, sanitary, and in good repair.

All resident bedrooms were inspected. Bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Bathrooms were checked. LPA observed toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Hot water temperature properly measured between 105.0 F and 120.0 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Continued on LIC809-C

Stephanie Cifuentes
Elvira Gonzalez
DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2026
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: SENIOR LIVING LIFESTYLE- PALOS VERDES
FACILITY NUMBER: 198601570
VISIT DATE: 10/05/2026
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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 a locked storage cabinet. First Aid kit was available. Fire extinguisher observed in the kitchen and fully charged. Carbon monoxide and smoke detectors in the house were operable.

LPA conducted a records review of three (3) staff records, two (2) resident service records, two (2) Medication Administration Records (MAR). No discrepancies were observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked.

Facility’s annual fees are current. Facility has an active Administrator Certificate for Robert Smith, #7009140740, valid 04/14/2026 through 04/13/2028. Facility has a current liability insurance with James River Insurance, policy #00127739-3, valid 02/20/2026 through 02/20/2027. The last fire drill was conducted 04/09/2026.

No deficiencies were cited during this inspection.

An exit interview was conducted, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Elvira Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2026
LIC809 (FAS) - (06/04)
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