Facility condition and maintenance
Cited in 2 reports, with 4 deficiencies in total.
EXCELLENCE BOARD AND CARE LLC
12551 DOWNEY AVE., Downey CA 90242
6 bedsLatest official report Mar 24, 2026Licensed
Additional info
- Telephone
- (818) 799-7218
- Licensee
- EXCELLENCE BOARD AND CARE LLC
- Administrator
- ESPINAL, ALMA
- Contact
- ESPINAL, ALMA
- License first date
- Jan 19, 2024
- License effective date
- Jan 19, 2024
- District office
- MONTEREY PARK ASC · (323) 980-4934
- Regional office
- 28
- Clients served
- 983 - RCFE / DEMENTIA, 985 - RCFE / HOSPICE
Summary
The available records show 4 Type A and 9 Type B deficiencies for this facility.
- Most recent inspection
- Jan 22, 2026
- Most recent deficiency
- Jan 22, 2026
1 later report, on Mar 24, 2026, recorded no deficiencies, though the records do not say whether they were follow-ups.
What Type A and Type B mean
- Type A
- 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
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 1,564 Los Angeles County facilities licensed for 6 or fewer beds.
In the available public five-year record, CCLD published 7 reports for this facility: 2 inspections, 1 complaint investigation, and 4 licensing or administrative records.
Those records contain 4 Type A and 9 Type B deficiencies.
0 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 2
- Recorded deficiencies
- 13
- Type A deficiencies
- 4
- Type B deficiencies
- 9
- Substantiated complaints
- 0
- Repeated topics
- 2
Fewer than the typical 4
1 in the last 12 months
Well above the typical 1
5 in the last 12 months
Most this size have none
1 in the last 12 months
Most this size have none
4 in the last 12 months
Most this size also have none
0 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Medication handling and storage
Cited in 2 reports, with 3 deficiencies in total.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Complaint
Allegations0 substantiated · 5 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportLicensing recordNot an inspection of the operating facility
No deficiencies recorded in this report
Inspection
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(h)(2)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above medication key was left in file cabinet making medication accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/23/2026 Plan of Correction Licensee will conduct training with staff on section 87465(h)(2) and return to LPA by POC due date.
Plan of correction recorded
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)
- Regulation authority
- CCR
What the official deficiency says
(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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above backyard had old furniture, metal, and other debris in backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/29/2026 Plan of Correction Licensee will clear backyard and send LPA pictures by POC due date.
Plan of correction recorded
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(e)(6)
- Regulation authority
- CCR
What the official deficiency says
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above bathroom #3 sink did not work at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/29/2026 Plan of Correction Licensee will call plumber and have sink fixed and send receipts to LPA by POC due date.
Plan of correction recorded
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(2)
- Regulation authority
- CCR
What the official deficiency says
This requirement is not met as evidenced by:87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above all three residents had cameras in bedrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/29/2026 Plan of Correction Licensee removed cameras at time of visit. Licensee can submit a facility wide waiver for cameras in private areas, or submit individual exceptions for each resident.
Plan of correction recorded
Correction not verified in available records
Not classified in the sourceType B
- Official classification
- Type B
- Official code
- 86468.2(a)(1)
- Regulation authority
- CCR
What the official deficiency says
This requirement is not met as evidenced by:87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in LPA observed open alcohol accessible to residents at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/29/2026 Plan of Correction Licensee will have a meeting with staff to discuss no alcohal allowed at facility. Licensee will also do insepections of staff rooms to insure they are following rules. Licensee will draw up paperwork with staff and have staff sign and send to LPA by POC due date.
Plan of correction recorded
Correction not verified in available records
Inspection
Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above LPA observed cleaning products stored inside a kitchen cabinet underneath the sink accessible to residents. The cabinet did not have a lock or other safety mechanism in place to prevent access. Cleaning products included (2) powder cleanser (Bar Keepers Friend). Located in the kitchen island cabinet were (2) cleaning sprays Weiman Stainless Steel and an unidentified cleaning solution. The cabinet did not have a lock or safety mechanism. Stored in the pantry cabinet unlocked and accessible to residents was a can of butane fuel (First Street brand). In the unlock laundry area was (2) Clorox and (1) detergent bottle which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/23/2024 Plan of Correction Licensee will remove the disinfectants, and cleaning solutions and placed them in a secure location. Licensee to provide In-Service training for all staff on cleaning solutions being inaccessible to clients. The In-Service Training will include list of attendees’ names and attendees’ signatures. Licensee will provide proof of In-Service Training to licensee by POC Due Date
Plan of correction recorded
Correction not verified in available records
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above R1's PM Medication- Temazepam 15 mg QTY 30 (Take 1 capsule by mouth at bedtime) . R1's PM Medication- Temazepam 15 mg QTY 30 (Take 1 capsule by mouth at bedtime) . R2's AM Medication - Eliquis 2.5 MG (Take 1 tablet by mouth every morning and evening) . R2's AM Medication- Senna Plus 50-8,6 MG (Take two tablets by mouth every morning and evening).. R2's AM Medication - Risperidone 0.5 MG ( Take 1 tablet by mouth every morning and evening) November 4th - November 11th 2024 medication was not administered no supporting documents was provided for the reason. R2's Evening Medication - Senna Plus 50-8,6 MG (Take two tablets by mouth every morning and evening) was not administered no supporting documents was provided for the reason which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/23/2024 Plan of Correction Licensee will provide LPA with thefollowing documents in-service training for all staff on medication, and that R1's and R2's physician was notified by POC Due Date. The In-Service Training will include list of attendees’ names and attendees’ signatures.
Plan of correction recorded
Correction not verified in available records
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(h)(2)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above LPA observed in the office area a filing cabinet ajar and unlocked contents were residents and staff medication. In staff room #1 the door was unlocked and medication was present and accessible to residents. Located in the dresser in the dining room was a (1) bubble pack of pills Hydroxyzine HCL 25 MG in the drawer which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/23/2024 Plan of Correction Licensee will ensure that all medication is kept safe and in a locked place that is not accessible to person other than employees responsible. Licensee will provide in-service training for all staff on the ensuring medication is secured. The in-service training will include list of attendees names and attendees signatures. Licensee will provide proof of in-service training to CCL by POC Due Date.
Plan of correction recorded
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)
- Regulation authority
- CCR
What the official deficiency says
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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above LPA observed a closet door in resident #1 (R1) room was inoperable. The issue appeared to be caused by significant rust damage to the door track, preventing proper opening and closing. LPA observed in the backyard outside the shed a mattress, shopping cart, television, two (2) dressers, and an unhinged door. On the side of the shed was broken pieces of tile which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/29/2024 Plan of Correction Licensee will ensure the facility and backyard is clean and in good repair for residents. Licnesee will provide pictures and/or recipts of closet door being fixed and cleaned of rust. Documents will be submitted to CCL by POC Due Date
Plan of correction recorded
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(e)(2)
- Regulation authority
- CCR
What the official deficiency says
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above he one (1) half bath in the kitchen water temperature measured at 71.4 degrees f, restroom #4 water temperature measured at 86.7 degrees f., and restroom #9 outside water temperature measured below the 105 degrees f. which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/29/2024 Plan of Correction Licensee will maintain water temperature between 105 - 120 degrees F, Licensee will develop a water log and record water temeratures every 24 hrs for the next 5 calendar days. Documents will be submitted to CCL by POC Due Date
Plan of correction recorded
Correction not verified in available records
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(c)(3)
- Regulation authority
- CCR
What the official deficiency says
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above PRN medication Trazodone Hyrochlor 50mg Tab for R2 is being given daily with no record of dosage and resident's response and both R1 and R2 was missing their medication sheet for the month of November 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/29/2024 Plan of Correction Licensee will provide LPA with thefollowing documents an up dated medication sheet for R1 and R2 and notified R2's physican that PRN medication has been given daily November 1st - November 22nd 2024.
Plan of correction recorded
Correction not verified in available records
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(c)
- Regulation authority
- HSC
What the official deficiency says
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above Licensee Rey did not have any documents supporting an Emergency Disaster Drill was completed which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/29/2024 Plan of Correction Licensee will conduct an emergency disaster drill and provide documentation to CCL by POC Due Date.
Plan of correction recorded
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87608(a)(5)(B)
- Regulation authority
- CCR
What the official deficiency says
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above LPA observed resident #1 (R1) with full bed rails and R2 with half bed rails. R1 is not receiving hospice care. Licensee does not a have a note from physician for half bed rails for R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/29/2024 Plan of Correction Licensee agrees to submit a physician's order for R1 & R2's bed rails. The order will specify the length of the bed rail.
Plan of correction recorded
Correction not verified in available records
Licensing recordNot an inspection of the operating facility
No deficiencies recorded in this report
Licensing recordNot an inspection of the operating facility
No deficiencies recorded in this report
Licensing recordNot an inspection of the operating facility
No deficiencies recorded in this report
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology