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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602210
Report Date: 08/31/2026
Date Signed: 08/31/2026 03:21:20 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/31/2026 03:21 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:INDIAN PEAK MANORFACILITY NUMBER:
198602210
ADMINISTRATOR/
DIRECTOR:		TORRE, RICARDO DELAFACILITY TYPE:
740
ADDRESS:27102 INDIAN PEAK ROADTELEPHONE:
(424) 206-2292
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90274
CAPACITY: 6CENSUS: 5DATE:
08/31/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:22 AM
MET WITH:Glenda MarquezTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 08/31/26, the department conducted an unannounced 1-year required annual visit to the above-named facility. The department met with Administrator, Glenda Marquez, and the purpose of the visit was explained. The department was granted entry to the facility. The facility is licensed to serve residents 60 years and above. The capacity is for six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility has a hospice waiver for two (2) residents. Currently, the home has five (5) residents. The facilities annual fees are current.

The facility is a single story home located in a residential neighborhood, and it consists of the following: four (4) bedrooms, two (2) bathrooms, kitchen, living room, dining area, laundry area, an attached garage, and outside shaded area.

Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to clients. There are no security bars or weapons on the premises. All resident bedrooms were checked. Beds and beddings were in good condition, adequate lighting provided, adequate storage for resident’s personal belongings was observed. Walls and floors were clean and in good condition. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations.

Bathroom toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible for resident’s use.

Continued on LIC809-C

Stephanie Cifuentes
Elvira Gonzalez
DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: INDIAN PEAK MANOR
FACILITY NUMBER: 198602210
VISIT DATE: 08/31/2026
NARRATIVE
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The water temperature properly measured between 105.0-120.0 degrees Fahrenheit. A comfortable temperature is maintained in the facility. Storage areas for cleaning agents, toxins, and sharps were inaccessible to residents.

The kitchen was inspected, and there is enough perishable and non-perishable food available for the residents. All food items were stored properly. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked, along with manual. Smoke and carbon monoxide detectors were operable. Fire extinguishers were fully charged. Toxins and knives were locked and inaccessible to residents.

The department conducted a review of four (4) staff records and observed them to be complete, and five (5) client records, and observed them to be complete, in order, and with no discrepancies.

During the visit, the department observed the facility infection control practices. The department observed screening protocols for visitors, staff, and residents. The department observed sanitizing stations were in common areas and restrooms. The department observed that the facility had the required postings posted as mandated throughout the facility. Last fire drill was conducted on 08/15/26. Active Administrator certificate for Glenda Marquez, #7001021740, effective 05/15/25, expires 05/14/27. Liability Insurance with Perlas Insurance Services, Policy #01004460160, effective 04/21/26, expires 04/21/27.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during today’s visit will be documented on LIC809-D

An exit interview was conducted and a copy of this report was discussed and left with Glenda Marquez.

* Please note that due to technical difficulties, the department was unable to generate an electronic inspection tool and instead used a printable/PDF version.

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

DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/31/2026 03:21 PM - It Cannot Be Edited


Created By: Elvira Gonzalez On 08/31/2026 at 01:14 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: INDIAN PEAK MANOR
FACILITY NUMBER: 198602210

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2026
Section Cited
CCR
87458(c)(1)

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87458(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:

This requirement is not met as evidenced by:
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Licensee will ensure that proper annual Medical Assessment LIC 602A for all residents in care. Licensee will provide current medical assessment, LIC 602A for resident #1, and #4. Proof of correction must be sent to LPA elvira.gonzalez@dss.ca.gov
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified that Residents #1, and #4 did not have a current Medical Assessment, LIC 602A. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
09/14/2026
Section Cited
CCR87456(a)(2)

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87456(a): Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2): Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
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Licensee will adhere to Title 22 Reg 87456(a)(2). Licensee will ensure all residents in care must have Needs Service Plan/Appraisal on file. Proof of correction must be sent to LPA elvira.gonzalez@dss.ca.gov
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified no Needs Service Plan Appraisal for Resident #1, #2, #3, and #4. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:
Elvira Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/31/2026 03:21 PM - It Cannot Be Edited


Created By: Elvira Gonzalez On 08/31/2026 at 01:16 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: INDIAN PEAK MANOR
FACILITY NUMBER: 198602210

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2026
Section Cited
CCR
87303(a)

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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:
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Licensee/Administrator to submit plan, including pest control receipts, to LPA by POC due date detailing what the facility is going to do regarding pest control throughout the facility. What measure will be added to cleaning procedures to ensure pests at the facility is under control to ensure residents’ health and safety. Proof of correction must be sent to LPA Elvira.gonzalez@dss.ca.gov
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This deficiency was not met as LPA observed live cockroaches in facility kitchen cabinets, on the kitchen table, and on the living room floor, which poses a potential health and safety risk to residents in care.
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Type B
09/14/2026
Section Cited
CCR87307(d)(6)

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87307(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.

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Licensee/Administrator will send LPA pictures once items have been removed, and cleared, and remind staff to keep outside, passageways, clear and remove anything that may be a tripping hazard to residents. Proof of correction must be sent to LPA Elvira.gonzalez@dss.ca.gov
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Based on observation, the licensee did not comply with the section cited above, as the backyard was full of boxes, shoes, clothing, clutter, and old/unused items, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:
Elvira Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2026


LIC809 (FAS) - (06/04)
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