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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191801803
Report Date: 08/11/2023
Date Signed: 08/11/2023 02:15:28 PM


Document Has Been Signed on 08/11/2023 02:15 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: 21DATE:
08/11/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Leo Del Rosario, AdministratorTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza generated this Case Management - Deficiencies report in conjunction with complaint control # 28-AS-20230804120943 pertaining to observations made during file review. The purpose of the report was explained to Administrator Leo Leo Del Rosario.

Resident (R1's) file was reviewed. The last Physician's Report on file is dated 10/4/2017. On 6/26/2023, R1 was sent to the hospital and returned to the facility with documentation identifying changes in condition. Resident (R1) has been noted by staff to be forgetful and irritable. The facility has not re-assessed the resident or obtained a current Physician's Report.

Deficiency is cited.

An exit interview was conducted and a copy of the report and appeal rights were issued to Mr.Del Rosario.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
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 2


Document Has Been Signed on 08/11/2023 02:15 PM - 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: GARDEN CREST
FACILITY NUMBER: 191801803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2023
Section Cited
CCR
87463(3)

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Reappraisals- The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:
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Administrator agreed to obtain an updated Physician's Report, re-assess R1, and submit proof by POC due date.

NOTE: IF changes in a residents physical condition is observed, staff shall update and document the reappraisal in the residents file.
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Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions.
**Staff did not re-appraise Resident #1 (R1) after 6/26/23 incident.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
LIC809 (FAS) - (06/04)
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