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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191801803
Report Date: 11/30/2021
Date Signed: 11/30/2021 12:16:23 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GARDEN CRESTFACILITY NUMBER:
191801803
ADMINISTRATOR:CAROL ICEFACILITY TYPE:
740
ADDRESS:889 LUCILE AVETELEPHONE:
(323) 663-8281
CITY:LOS ANGELESSTATE: CAZIP CODE:
90026
CAPACITY:44CENSUS: 19DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Leo Del Rosario TIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Programming Analysts(LPAs) Mary Flores and Jewel Baptiste conducted and unannounced annual visit with focus on infection control domain, food and medication review. LPAs met with Leo Del Rosario and explained the reason for the visit.

The facility is licensed to serve 44 residents over the age of 60 of which up to 18 may be non-ambulatory residents, is approved for 4 hospice waivers, and 6 bedridden in assigned rooms. Facility is a two story building with a kitchen, dining room, library/ laundry room, activity room, 2 common bathrooms, 2 staff bathrooms, 1 resident shared shower room down stairs, residents bedrooms with private bathrooms and a medication room. Facility has multiple fire extinguishers and carbon monoxide detectors with a sprinkler fire system throughout the facility.
LPAs and administrator toured the facility which included: random bedrooms which include room # 81, 84, 88, 65 and 68. All rooms were clean, odor free and had the required furniture of one desk, chair, dresser, lamp and linens. Bathroom were clean, toilets and water faucets worked properly and have the required grab bars and skid mats. Water temperature was tested the residents bathrooms and it was tested between 108.7 and 115.7 degrees F, which is within the required 105 - 120 degrees F. LPAs observed mold in shower chair of the facility common shower. Facility has operational emergency pull alarms in the resident bathrooms and bedrooms. LPAs toured the kitchen and observed sufficient food supplies for at least of 7 days of non-perishable and 2 days of perishable. LPA observed water damage in medication room approximately 2 x 3 feet. Medication was reviewed for residents #1 and #2.
Facility is following COVID 19 recommendations of daily screening for staff, residents, and visitors. Signs are posted throughout the facility. Staff have been fit test for N95s. The facility has sufficient PPE supplies for at least 30 days.
Deficiencies were observed during the visit and noted on LIC 809D, Per California Code of regulations, Title 22. Exit interview was conducted with Leo Del Rosario administrator and a copy of the this report, LIC 809D, and appeals rights were given.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARDEN CREST
FACILITY NUMBER: 191801803
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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
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Based on observation, the licensee did not comply with the section cited above by LPAs observed water damage in medication room and mold in the shower chair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2021
Plan of Correction
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Licensee will repair water damage in medication room and replace shower chair and submit pictures to the department by 12/14/21.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021
LIC809 (FAS) - (06/04)
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