197602106-1-6-2023-11-AS-WGIS-CMJUVB-20221228145452

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602106
Report Date: 12/28/2022
Date Signed: 01/06/2023 04:41:23 PM

Document Has Been Signed on 01/06/2023 04:41 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: 54	DATE:	12/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:13 AM
MET WITH:	Bernice Pulanco		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced Annual visit with the primary focus on infection control using the CARE tools. LPA was met by Administrator, Bernice Pulanco, and the purpose of today’s visit was explained. Currently there are 54 residents, 11 are ambulatory and 43 of are non-ambulatory.

Structure/Physical Plant The facility is a 4-story building structure located in a residential neighborhood. It consists (37) bedrooms, (47) bathrooms, lobby floor contains: front desk, office, tearoom, activity room, dining room, living room, TV room, laundry room, kitchen/ food storage, 2 elevators, and common restrooms. The 1st residential floor contains: arts/crafts room, beauty shop, medication room, 2 storage rooms, janitor closet, 1 linen closet, outside seating patio with chairs and umbrellas, and common restrooms. The 2nd floor residential floor contains: common restrooms, synagogue, janitor closet, PPEs storage room # 214, linen closet, and janitor's closet. The 3rd floor residential floor contains: common restroom, library, janitor closet, 1 storage closet, and 1 linen closet. The front of the building is landscaped and there is a basement garage.

Rooms/Apartments LPA Gibbs and Bernice toured the entire facility, inside and out. Three to four rooms were toured on each floor. All the rooms toured were occupied by residents except for one. Each room had the required furniture, including a bed, chair/couch, dresser, nightstand, lamp and ample closet space. Residents have the option to furnish rooms with their own belongings or keep the furnishings that is in there.

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.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS CARMEL RETIREMENT HOTEL	FACILITY NUMBER: 197602106
	VISIT DATE: 12/28/2022

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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 114.6-118.3-degrees Fahrenheit. All 8 resident bathrooms were in good working order. 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. The water temperature measured between 114.2 to 118.9-degrees Fahrenheit.
Kitchen LPA and Bernice toured the industrial kitchen. 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 in. 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.
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 on 5/18/2022. All fire extinguishers were fully charged and last serviced on 03/04/2022. The last emergency drill was on 12/06/2022. All exits were marked, and signs posted. The elevators were last maintenanced and inspected on 07/27/2022. The First Aid Kit was inspected and found to contain all the required items and a manual.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS CARMEL RETIREMENT HOTEL	FACILITY NUMBER: 197602106
	VISIT DATE: 12/28/2022

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Infection Control During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors’ temperatures are checked and logged, sanitizer/soap throughout the facility and additional sanitation supplies are locked in room 214. LPA observed all staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The resident’s temperatures are checked and logged after outings. Also residents are tested if displaying Covid symptoms or have been exposed. PPEs are enough for 60 days.

Files LPA reviewed 6 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 4 residents’ medication.

LPA reviewed the Liability Insurance which expires on 03/01/23.

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 Bernice Pulanco, Administrator and copy of report provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

LIC809 (FAS) - (06/04)

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