191600500-5-25-2021-11-AS-TAGD-C3CUBB-20210525152605

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191600500
Report Date: 05/25/2021
Date Signed: 05/25/2021 03:27:10 PM

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	NAZARETH HOUSE		FACILITY NUMBER:	191600500
ADMINISTRATOR:	JODI KANOWITZ		FACILITY TYPE:	740
ADDRESS:	3333 MANNING AVENUE		TELEPHONE:	(310) 839-2361
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90064
CAPACITY:	158	CENSUS: 98	DATE:	05/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:34 PM
MET WITH:	Administrator, Jodi Kanowitz		TIME COMPLETED:	03:00 PM

NARRATIVE

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On 05/25/2021 at 12:34pm, Licensing Program Analyst (LPA) Troy Agard conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival at the facility, LPA Agard called Administrator, Jodi Kanowitz and conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

LPA met with Administrator, Jodi Kanowitz and toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked by receptionist. LPA was properly equipped with Fit tested N-95. Facility is licensed for a capacity of 158 with 98 non-ambulatory, hospice waiver for 15. The facility currently has 98 residents in total.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the entrance (and throughout the facility), visitors log with Covid-19 screening, temperature log, and records of daily Covid-19 screening and temperature checks for staff and visitors were observed, separately. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored. LPA observed residents and staff maintain 6 feet physical distancing, and each person (staff) wears a face covering. LPA observed required postings throughout the facility.

The facility is 2- stories that consists of 136 resident bedrooms, 136 resident bathrooms, lobby area, media room, reading room, activity room, dining room, 3 med rooms, 4 elevators, Bistro, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. A vacant unit was inspected, and the water temperature was tested at 109F. Facility was observed in good repair, adequate lighting provided, storage for resident’s’ personal belongings was observed.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

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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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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: NAZARETH HOUSE	FACILITY NUMBER: 191600500
	VISIT DATE: 05/25/2021

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Furniture in common area was in good repair. Common areas were clean and clear of hazards; doorways were free of obstructions. All exit doors in the Dementia unit have auditory alarms. There are no security bars or weapons on the premises. The bathroom was checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. A comfortable temperature was maintained in the facility.

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. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. Fire extinguishers were observed throughout the facility.

Outside grounds were toured, 3 water fountains were observed. All three do not pose a danger to residents in care. Walkways around the facility were clear of hazards.

No deficiencies were cited during this visit.

No advisory notes were issued.

An exit interview was conducted, and a copy of this report was provided to Administrator, Jodi Kanowitz.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

LIC809 (FAS) - (06/04)

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