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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191801803
Report Date: 10/25/2022
Date Signed: 10/25/2022 12:53:32 PM


Document Has Been Signed on 10/25/2022 12:53 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
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: 23DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Leo Del RosarioTIME COMPLETED:
01:15 PM
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Licensing Programming Analyst (LPA) Christine Wong conducted an unannounced annual visit with focus on infection control domain, food and medication review. LPA met with staff Jocelyn Moran and explained the purpose of the visit and shortly after, the administrator Leo Del Rosaro arrived and assisted with 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, TV room, 2 common shower rooms, 2 staff bathrooms, two residents shared rooms on the first floor, 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.
LPA and administrator toured the facility which included: random bedrooms which include room #67, #69, #85, #88. 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 114.9 and 118.2 degrees F, which is within the required 105 - 120 degrees F. Facility has operational emergency pull alarms in the resident bathrooms and bedrooms. LPA toured the kitchen and observed sufficient food supplies for at least of 7 days of non-perishable and 2 days of perishable food supply. Medication was reviewed and the medication seemed accurate and updated. LPA also checked all three residents emergency contact information and they are all updated. LPA also reviewed three staff staff files and they are all fingerprint cleared and have updated health screening form in file.

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.
No deficiencies were observed during the visit. Exit Interview conducted and a copy of the report was provided to Administrator Leo Del Rosario.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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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