<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191805183
Report Date: 11/16/2022
Date Signed: 11/16/2022 01:19:35 PM


Document Has Been Signed on 11/16/2022 01:19 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:ST. JOHN OF KRONSTADT HOMEFACILITY NUMBER:
191805183
ADMINISTRATOR:LIANA VERTELKINAFACILITY TYPE:
740
ADDRESS:655 NO. SERRANOTELEPHONE:
(323) 466-6467
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY:21CENSUS: 12DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Liana VertelkinaTIME COMPLETED:
10:30 AM
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 Analyst (LPA) Alma Gonzalez conducted an unannounced Annual Required / Infection Control visit to the above facility. LPA was met by Administrator Liana Vertelkina and the purpose of today’s visit was explained.

This is an RCFE with a capacity of 21. The facility is licensed to serve 21 ambulatory residents, ages 60 years and over.



LPA and Administrator Liana Vertelkina toured the facility's physical plant inside and outside to ensure there are no health and safety hazards. LPA toured the common areas, resident rooms which include private restrooms, kitchen, dining area, public restrooms and outside patio/ smoking area. The following was inspected and toured: 19 resident bedrooms which consist of 18 single and 1 shared room, each bedroom has a sink and toilet. There is a recreation room, Kitchen, Dining hall, laundry room, medication room, 3 storage rooms, 3 baths and 1 shower, Office, Staff restroom and visitor restroom and outside shaded patio. All common areas were properly furnished and appeared comfortable. Resident bedrooms had the required furniture for comfort and safety and had sufficient lighting. All indoor and outdoor passages were free of obstruction. All bathrooms were observed to be clean and had the required hygiene items. Bathrooms all have a supply of hand soap and paper towels. Bathrooms had grab bars for each toilet, bathtub/shower and LPA also observed non-skid mats and/ or strips in resident bathtubs/ shower. All bathrooms were observed to be clean. Linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents. The hot water temperature measured 111 F, which is within the required 105 - 120 degrees. There is sufficient lighting throughout the facility. There are no large bodies of water on the premises such as pools. The grounds are well groomed and there were no hazards observed. Cleaning supplies are inaccessible to clients. The front exterior of the facility is clear of debris with steps and ramp leading to the facility entrance.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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


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: ST. JOHN OF KRONSTADT HOME
FACILITY NUMBER: 191805183
VISIT DATE: 11/16/2022
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
26
27
28
29
30
31
32
Trash containers have covered lids. There are no security bars nor weapons on the premises. LPA observed the facility to be in good repair. Smoke detectors and carbon monoxide detector were in compliance and operational. Medications are properly stored, locked and inaccessible to clients.

The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms bathrooms and hallways.
  • Facility is conducting COVID-19 screening for all visitors.
  • Residents are able to use a designated isolation room that will be used as isolation room if a COVID-19 positive case should arise.
  • 30 day supply of medication for residents
  • Facility has an adequate amount of PPE and facility has enough PPE for 60 + days.
  • Residents were socially distanced according to local public health guidelines.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Hand Sanitizer: Available throughout the facility for client use.
  • The resident's temperature is checked and logged daily.
  • Staff temperatures are checked and logged daily.
  • Staff and residents are tested only if showing symptoms for COVID19.
  • All residents and staff are fully vaccinated and have received both booster vaccines for COVID-19.


According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator Liana Vertelkina and copy of report provided.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2