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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600500
Report Date: 05/12/2023
Date Signed: 05/12/2023 04:23:54 PM


Document Has Been Signed on 05/12/2023 04:23 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:NAZARETH HOUSEFACILITY NUMBER:
191600500
ADMINISTRATOR:WILLIAM BOLES JRFACILITY TYPE:
740
ADDRESS:3333 MANNING AVENUETELEPHONE:
(310) 839-2361
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY:158CENSUS: 87DATE:
05/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Kristin BeckTIME COMPLETED:
04:00 PM
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On 05/12/2023 at 8:45am, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced required annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Gibbs conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. LPA met with Director of Nursing, Dory Polo and explained the purpose of today’s visit. We were later joined by Executive Director, Kristin Beck. The facility is licensed for a capacity of 158 with 98 non-ambulatory, hospice waiver for 20. The facility currently has 87 residents in total.
Structure The facility is 2- story building that consists of 136 resident bedrooms, 136 resident bathrooms, Chapel, lobby area, media room, reading room, activity room, dining room, 3 med rooms, 4 elevators, Bistro, and kitchen.
Physical Plant LPA toured the inside and outside grounds of the facility. LPA observed 3 water fountains. All three do not pose a danger to residents in care. LPA observed multiple shaded seating area that have table and chairs. The grounds and gardens are well maintained. LPA observed all walkways around the facility to be clean, clear, and free of hazards, obstructions, and debris.
Bedrooms LPA inspected two (2) vacant units. LPA observed the units to have the required furniture including a bed, dresser, nightstand with lamp, chair, and storage for personal belongings. All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens stored in a supply room. Rooms were observed to be in good repair and have ample lighting.
Bathrooms The bathrooms were checked, LPA observed a sufficient liquid soap and paper towels. LPA observed the toilets and water faucets worked properly. All grab bars were secure, showers had nonskid mats, and the shower was free of mold/mildew. LPA observed an ample supply of towels, washcloths, and hand towels stored in supply room. The water temperature measured between 107.2- and 116.2-degrees Fahrenheit.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: NAZARETH HOUSE
FACILITY NUMBER: 191600500
VISIT DATE: 05/12/2023
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 Common Rooms Furniture in common areas were in good repair. LPA observed all common areas, and hallways were clean and clear of hazards; doorways were free of obstructions. LPA observed activities, books, exercise equipment for resident use. A comfortable temperature was maintained in the facility.
Kitchen LPA toured the kitchen area and observed a three-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were secured and inaccessible to residents. LPA observed all appliance to be in good working repair. LPA observed an ample supply of cutleries, pots and pans to be in good repair. LPA observed the kitchen to be clean and sanitary.
Medications All medications were stored in three different Med Rooms throughout the facility. LPA inspected all 3 rooms. All medications are in there original packaging and stored in a locked med cart and are inaccessible to residents. LPA reviewed medications for 9 residents and matched them to the MARs.
Safety LPA observed all exits to be clearly marked. Outside of all elevators and near all exit door is a facility sketch with evacuation routes marked. LPA observed fire extinguishers to be fully charged and last serviced on 05/09/23. The last emergency drills for each shift were conducted on 02/01/23 (1st shift), 03/31/23 (3rd shift), and 04/28/23 (2nd Shift). LPA observed the First Aid Kit to be fully stocked and containing the required items including a manual. The elevator was last inspected and serviced on 04/26/22. LPA observed all required postings throughout the facility. The Diesel generator was last serviced on 03/23/23, and is ran weekly. LPA did not observe any security bars on the premises. There are no firearms or ammunition stored on the premises.
Infection Control 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 screening, temperature log, and records of daily 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 some residents and staff wearing face coverings. LPA observed required infection control postings throughout the facility.
Files & Interviews LPA reviewed 6 resident files and found they contained the required documentation. During interviews all six (6) residents were happy here and felt their needs were met. LPA reviewed 6 staff files and found they contained the required documentation, certification, and training. LPA interviewed six staff members. All staff interviewed were able to explain policy, procedure, and personal rights. LPA reviewed and received copies of the Emergency Disaster Plan (LIC610E), Licenses, Personal Rights, Nondiscrimination Policy, Activity Schedule, Menu, Dietitians Quarterly Assurance Report, Theft and Loss Policy and Resident Council Notes.

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 Executive Director, Kristin Beck

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC809 (FAS) - (06/04)
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