191801803-9-22-2023-28-AS-THEA-CVWUHD-20230922153545

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191801803
Report Date: 09/22/2023
Date Signed: 09/22/2023 03:35:57 PM

Document Has Been Signed on 09/22/2023 03:35 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GARDEN CREST		FACILITY NUMBER:	191801803
ADMINISTRATOR:	CAROL ICE		FACILITY TYPE:	740
ADDRESS:	889 LUCILE AVE		TELEPHONE:	(323) 663-8281
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90026
CAPACITY:	44	CENSUS: 28	DATE:	09/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Leo B Del Rosario - Administrator		TIME COMPLETED:	03:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Leo Del Rosario (Administrator) and explained the purpose of today’s 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.

The facility is a two story building located in Los Angeles, CA. A tour of the facility includes: First Floor: 13 resident rooms, tv room, 2 public restrooms, 2 shower rooms, janitor closet and linen closet. Second Floor: lobby / tv room, kitchen, dining/activity room, library/ laundry room, 2 common shower rooms, 2 staff bathrooms, 9 resident rooms (with private bathrooms), nurse station (medication room), janitor closet and linen closet. Facility has multiple fire extinguishers and carbon monoxide detectors with a sprinkler fire system throughout the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and there is an Infection Control Plan on file.

Operational Requirements: The facility maintains a plan of operation and has the required liability insurance on file.Physical Plant & Environment Safety: Smoke detectors and carbon monoxide detectors are operable and in compliance. Bathrooms are clean and operational. Residents’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. Nonskid mats were observed in shower rooms and residents private bathrooms. The outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees.
(Continued on 809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARDEN CREST	FACILITY NUMBER: 191801803
	VISIT DATE: 09/22/2023

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All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in a secured/locked area and inaccessible to residents. The last Fire/Emergency Drill was conducted on 8/29/2023. The fire extinguisher was observed and is fully charged. Facility has telephone service on premises.
Staffing: There appears to be sufficient staffing at all times in the facility with at least one CPR trained employee on the premises at all times. Administrator Leo Del Rosario certificate expires 3/3/24.
Personnel Records-Training: Staff has criminal record clearance, current first aid and CPR, and ongoing training. Staff files are maintained at the facility and kept in the Nurse Station. During todays visit LPA observed 5 staff files with no issues.
Resident Records-Incident Reports: Resident files are kept in a secure location within the Nurse Station and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA observed 5 resident files during todays visit with no issues.
Resident Rights-Information: Complaint and Personal Rights posters were observed in hall-way. Residents are provided with telephone and internet at the facility.
Planned Activities: There is an activity schedule posted outside the activity/dining room, LPA observed residents engaging in a craft activity during todays visit. There are board games and books readily available for residents in the library.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: All medications for residents are kept locked and inaccessible to other residents. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. During the visit today, LPA reviewed 5 residents’ medication no issues were observed.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The facility does not have evacuation chairs at each stairwell, this will be cited on 809-D page.
Residents with Special Health Need: “No Smoking-Oxygen In Use” signs are properly posted. There are no bedridden or residents or residents with postural supports at this facility.
Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on 809D.

Exit interview held and a copy of the report was provided to Administrator Leo Del Rosario.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/22/2023 03:35 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GARDEN CREST	FACILITY NUMBER: 191801803
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

1569.695(f)(1)

An evacuation chair at each stairwell on or before July 1, 2019. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as there was no evacuation chair observed in stairwell during visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Administrator to purchase evacuation chair and submit proof of purchase in form of receipt to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

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