197602106-7-5-2023-11-AS-DESA-CTFUKH-20230705153909

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602106
Report Date: 07/05/2023
Date Signed: 07/05/2023 03:39:18 PM

Document Has Been Signed on 07/05/2023 03:39 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	BEVERLY HILLS CARMEL RETIREMENT HOTEL		FACILITY NUMBER:	197602106
ADMINISTRATOR:	JOY ALVARADO		FACILITY TYPE:	740
ADDRESS:	8750 BURTON WAY		TELEPHONE:	(310) 278-9720
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY: 200		CENSUS: 56	DATE:	07/05/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	ADMINISTRATOR, Bernice Pulanco		TIME COMPLETED:	03:45 PM

NARRATIVE

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On July 5, 2023, at 8:05 AM Licensing Program Analyst (LPA) David España conducted an unannounced Annual visit. LPA was met by Administrator, Bernice Pulanco, and the purpose of today’s visit was explained. Currently there are 56 residents, 8 are ambulatory and 48 are non-ambulatory.

Linens LPA went inside all of the linen storage closets and found that they contained an ample supply of sheets, towels, mattress pads, blankets, comforters and pillows. Residents have the option to use and store their own linens. Each resident’s linens are changed weekly unless it is needed before that.

Bathrooms All common restrooms were checked by the LPA, as well as 8 resident bathrooms. All common restrooms had stalls that are wide enough to accommodate walkers or wheelchairs. Each stall contains safety grab bars that are securely fastened. They had an ample supply of soap and paper towels. The water temperature in the common restrooms measured between 105-120 degrees Fahrenheit. Each shower was free of mildew or mold, had secured safety bars, nonskid mat and some had a shower chair. All bathrooms were fully stocked with resident’s toiletries and hand soap. Resident’s bathrooms are cleaned daily.

Kitchen LPA and Bernice toured the industrial kitchen and dining room area. All appliances were in good, working condition. All food not stored in original container, were stored in a covered plastic container, and were labeled and dated. LPA observed a 4-day supply of perishable foods and a 7-day supply of non-perishable foods. LPA observed an ample supply of cutleries that were in good condition. Next to the pantry is a storage room where all the cleaning supplies are locked. All sharps are inaccessible to residents.

Common Rooms LPA walked through all common spaces. All areas had infection control signs posted. There was ample seating available for residents. LPA observed all walkways and doorways were free of hazards, obstructions, and debris. All areas had ample lighting available. The temperature was a comfortably maintained throughout the facility.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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 5

Document Has Been Signed on 07/05/2023 03:39 PM - It Cannot Be Edited

Created By: David Espana On 07/05/2023 at 02:44 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS CARMEL RETIREMENT HOTEL	FACILITY NUMBER: 197602106
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(4)

Personal Accommodations and Services

(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above.Licensing Program Analyst (LPA) David España and Administrator, Bernice Pulanco observed room 316/317 resident porch with uneven porch floor. Additionally, LPA and Administrator observed both outdoor patios (total of two) with wasps and wasps/hornet nest accessible to residents in care (i.e., exterminator may be required), which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2023
	Plan of Correction
1 2 3 4	The administrator/licensee agreed to have all fix uneven porch and wasps/hornet nest clearned for residents ensuring resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of records shall update the resident's/staff's needs and services plans within 30 days of today's 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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

David Espana

LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 07/05/2023 03:39 PM - It Cannot Be Edited

Created By: David Espana On 07/05/2023 at 02:44 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS CARMEL RETIREMENT HOTEL	FACILITY NUMBER: 197602106
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468(c)(2)(A)

Personal Rights of Residents

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above.Licensing Program Analyst (LPA) David España and Administrator, Bernice Pulanco observed front entryway of the facility to not have a PUB 475 poster meeting size requirements 20”X26,” which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2023
	Plan of Correction
1 2 3 4	The administrator/licensee agreed to have PUB 475 for residents ensuring resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of records shall update the resident's/staff's needs and services plans within 30 days of today's date.

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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

David Espana

LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 07/05/2023 03:39 PM - It Cannot Be Edited

Created By: David Espana On 07/05/2023 at 02:44 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS CARMEL RETIREMENT HOTEL	FACILITY NUMBER: 197602106
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(a)(1)

Other Provisions

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above. Licensing Program Analyst (LPA) David España and Administrator, Bernice Pulanco observed outdated Emergency Disaster Plan for Residential Care (LIC 610E), which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2023
	Plan of Correction
1 2 3 4	The administrator/licensee agreed to have current Emergency Disaster Plan for Residential Care (LIC 610E) for residents ensuring resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of records shall update the resident's/staff's needs and services plans within 30 days of today's 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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

David Espana

LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS CARMEL RETIREMENT HOTEL	FACILITY NUMBER: 197602106
	VISIT DATE: 07/05/2023

NARRATIVE

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Safety All rooms, common spaces and hallways were equipped with smoke and carbon monoxide detectors, as well as a sprinkler system which were serviced and checked by the Los Angeles Fire Department in May 2023. All fire extinguishers were fully charged and last serviced on 03/04/2023. The last emergency drill was in June 2023. All exits were marked, and signs posted. The elevators were last maintenance and inspected in June 2023. The First Aid Kit was inspected and found to contain all the required items and a manual.

Files LPA reviewed 5 resident files, and found they contained the necessary documentation. LPA reviewed 5 staff files and found they contained the necessary documentation and certification.

Medications All medications are stored and locked in the medication room on the 2^nd floor. LPA reviewed the MARs and matched it to 5 residents’ medication.

LPA reviewed the Liability Insurance which expires on 03/01/2024. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies, therefore citations were issued at this time.

Physical Plant/Environmental Safety - Type B: 87307(d)(4)

Resident Rights/Information - Type B: 87468(c)(2)(A)

Disaster Preparedness - Type B: 1569.695(a)(1)

An exit interview conducted with Bernice Pulanco, Administrator and copy of report, & appeal rights were provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC809 (FAS) - (06/04)

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