191802082-6-9-2022-31-AS-LQLY-CF8SCS-20220609134601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191802082
Report Date: 06/09/2022
Date Signed: 06/09/2022 01:46:49 PM

Document Has Been Signed on 06/09/2022 01:46 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SOLHEIM SENIOR COMMUNITY		FACILITY NUMBER:	191802082
ADMINISTRATOR:	CHO MAUNG		FACILITY TYPE:	741
ADDRESS:	2236 MERTON AVENUE		TELEPHONE:	(323) 257-7518
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90041
CAPACITY:	126	CENSUS:	DATE:	06/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Meg Pierce		TIME COMPLETED:	01:46 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) LaQueena Lacy and Gary Tan arrived at the facility at 10:10am on 06/09/2022 to conduct an unannounced One (1) year Required Infection Control visit. LPAs meet with Executive Director Meg Pierce and explained the purpose of this visit. The facility has an approved mitigation plan on file. A tour of the physical plant was conducted at 10:45am and the following was observed: The facility has a Memory Care, Residential Assisted Living , and Skilled Nursing Unit. The facility has a fire clearance for one hundred and twenty-six (126) non-ambulatory clients, and a hospice waiver for seven (07). The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette, and physical distancing) posted. The PPE screening station is located on a table near the entrance equipped with sufficient PPE readily accessible, hand sanitizer, gloves, and sign in sheet at the time of visit, and mask are kept at the receptionist desk across from the PPE screening station. The facility has a standing thermometer located near the entrance of the facility. Hand sanitizers are located on the walls throughout the facility and are full and operational. The facility also conducts antigen testing for visitors entering the facility. The facility has multiple fire extinguishers located throughout the facility to all have a service tag dated 01/24/2022. The smoke detectors are tested monthly and based on the LPAs observations of the monthly inspection reports that shows results as passed for all apartments. The facility is equipped with fire sprinklers. Continued on LIC809C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SOLHEIM SENIOR COMMUNITY	FACILITY NUMBER: 191802082
	VISIT DATE: 06/09/2022

NARRATIVE

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Kitchen: At 10:49am LPAs observed the kitchen to be clean and free from obstruction and inaccessible to residents. Appliances observed to be in good repair and functioning. The facility has a sufficient 7 days perishable and 2 days non-perishable food. The refrigerator (fresh fruit, vegetables, milk, bread, eggs, etc.) and the freezer (variety of meats, sandwich meat, desserts, and other dairy items) observed to be stocked and all properly labeled and stored. At 10:58 LPAs observed a two (02) rooms located near the entrance of the kitchen, one (01) to be storing a sufficient quantity of emergency food, the second to be storing brooms, mop buckets and cleaning supplies.
Bedrooms: At 11:15am LPAs observed eleven (11) random bedrooms that are equipped with private bathrooms. All bedrooms observed to be appropriately furnished with sufficient lighting. LPAs observed appropriately bed linen and comforters on all beds. All bedrooms observed to be clean and clear from obstruction are single occupancy. The facility has public bathrooms located throughout the facility for visitors.
Bathrooms: At 11:15am LPAs observed (11) bathrooms located inside of resident’s rooms to be clean and clear from obstruction. LPAs observed appropriate grab bars in shower and toilet area or a commode with handles around the toilet area. Bathrooms are stocked and equipped with soap and paper towels. The water temperature measured in range of 110.3 between 120.0 degrees Fahrenheit.
Medications: At 10:55am and 11:50am LPAs observed (02) nursing stations on the first floor in the memory care unit, and on the second floor in the resident assisted living unit, to be storing medication carts, first aid kit with manuals, and resident records. Medication carts, refrigerators used for medication and specimen collection were observed to be locked and inaccessible to residents. LPAs observed cupboards with medication baskets with resident names attached.

Continued on 809C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SOLHEIM SENIOR COMMUNITY	FACILITY NUMBER: 191802082
	VISIT DATE: 06/09/2022

NARRATIVE

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Living, dining room and common areas: At 11:25am LPAs observed the outdoor patio area for memory care and residential assisted living to have sufficient table and chairs for seating under a cover area. Table with owing and chairs also located in the covered patio area observed to clean and clear from debris and obstruction. The facility has multiple dining areas throughout the facility that has a kitchenet area (counter, sink and refrigerator) inaccessible to residents. No toxins or hazardous materials stored in these areas. The facility has bookshelves located in the hallways in the facility accessible to residents for enjoyment. All common areas are appropriately furnished with tables and chairs and adequate lighting. LPA observed the areas to be clean and free from debris. At 12:05pm LPAs observed a storage closet on the second floor near the elevator to be storing an emergency disaster kits, wheelchairs and extra linens and hand and bath towels.
Laundry Room: At 12:25pm LPAs observed the laundry room located in the basement to be inaccessible to residents clean and clear from obstruction.

No deficiencies cited, exit interview conducted, copy of report signed and issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC809 (FAS) - (06/04)

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