191221839-12-27-2022-28-AS-ACAN-CMHRCG-20221227115419

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191221839
Report Date: 12/27/2022
Date Signed: 12/27/2022 11:55:08 AM

Document Has Been Signed on 12/27/2022 11:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	BROADVIEW RESIDENTIAL CARE CENTER		FACILITY NUMBER:	191221839
ADMINISTRATOR:	BETSY K DAVIS		FACILITY TYPE:	740
ADDRESS:	535 WEST BROADWAY		TELEPHONE:	(818) 246-4951
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91204
CAPACITY:	180	CENSUS: 56	DATE:	12/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Administrator Betsy Davis		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Ashley Calderon conducted an unannounced Annual - 1 Year Required visit to this facility. Upon arrival, LPA met with Assistant Administrator / Dennise Alonso and later with Administrator Betsy Davis who assisted with the visit. During today's visit, LPA used the infection control tool to evaluate the facility. The facility has a hospice waiver for two (2) and currently has no residents on hospice. LPA and Davis toured the entire physical plant of the facility, the facility is a two-story building. Areas toured: the front lobby, dining area, activity spaces / common lounge areas, medication room, storage/ disaster rooms, resident common restrooms, laundry room, outside gardens, five (5) residents bedrooms and kitchen area. LPA observed that the facility does not have a swimming pool or other large body of water, small fountains were observed and were secured and fenced. All indoor and outdoor passageways were free of obstruction. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located and hand sanitizers are placed throughout the facility. All staff were observed to be wearing mask during this visit and facility had enough PPE supplies. LPA toured randomly selected resident rooms. Rooms 108, 118 were inspected on the first floor, rooms 222, 240 and 244 were inspected on the second floor. All bedrooms were furnished with required furniture. The resident's bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. Common resident restrooms were observed. One common restroom on the second floor was observed having a disinfectant bottle accessible to resident's, a deficiency was observed and cited on LIC809D . The hot water temperature was tested and measured within Title 22 Regulations guidelines, all were in measured between 110.5 - 118.9 Fahrenheit. Smoke detectors are present throughout the facility and in resident bedrooms. Fire extinguishers are fully charged and present throughout the facility, oxygen monoxides are operable, and fire alarms are wired to the Glendale Fire Department. Continuation 809-C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BROADVIEW RESIDENTIAL CARE CENTER	FACILITY NUMBER: 191221839
	VISIT DATE: 12/27/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. LPA observed sufficient supply of perishable and non-perishable foods, food menu was posted and no foods were expired. Common areas were observed clean and properly furnished. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations.

Deficiencies were noted during this visit on LIC 809D per Title 22 Regulations.

A copy of the report was provided to the administrator and appeal rights were given.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 12/27/2022 11:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BROADVIEW RESIDENTIAL CARE CENTER	FACILITY NUMBER: 191221839
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, in the second floor common resident restroom had a disinfectant bottle not locked and accessible to residents in care, poses/ posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2022
	Plan of Correction
1 2 3 4	Administrator immediately removed disinfectant bottle and stored it in a locked storage room were all chemicals and disinfectant supplies are stored and inaccessible to the residents. Administrator will train staff on providing information how to properly store chemicals and disinfectiants to be inaccessible to residents in care, a in service training form will be provided to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3