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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602370
Report Date: 09/02/2023
Date Signed: 09/02/2023 03:11:05 PM


Document Has Been Signed on 09/02/2023 03:11 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 NORTHFACILITY NUMBER:
197602370
ADMINISTRATOR:ARIELLA BENBASSATFACILITY TYPE:
740
ADDRESS:8757 BURTON WAYTELEPHONE:
(310) 278-8323
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:138CENSUS: 40DATE:
09/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Ariella Benbassat-AdministratorTIME COMPLETED:
03:10 PM
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On 9/2/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Ariella Benbassat/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (138) elderly adults ages 60 and above, of which (40) may be non-ambulatory on 1st and 2nd floor. Facility has an approved hospice waiver for (3).

The facility is a 4-story structure located in a residential neighborhood. It consists of (79) bedrooms, (8) common area bathrooms, (79) full private bathroom, shaded back yard, front yard, 1st Floor: Lobby, Receptionist desk, library, elevator activity room, storage, salon Administrators office, kitchen, laundry room, linen closet, PPE storage, 2nd Floor: patio, card room, janitor's closet, linen closet, 3rd Floor; linen closet, storage, janitor's closet, electrical closet.

LPA Iniguez toured the physical plant with Administrator. There were no bodies of water or obstructions on the premises. A total of (7) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #101, #106, #201, #217, #308, #403, #420; call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 109.5F° – 114.2F°. The rooms temperature ranged from 76F° – 78F°.

Evaluation Report continues on LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS CARMEL RETIREMENT HOTEL NORTH
FACILITY NUMBER: 197602370
VISIT DATE: 09/02/2023
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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 08/20/23. Annual fire clearance performed on 6/23/2023. Working landline phones are available on-site. A review of (5) residents' service files (R1-R5) and (5) staff personnel files (S1-S5) and Medication Administration Records (MAR) were maintained in order.

LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted throughout the facility.

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




An exit interview was conducted, and a copy of the Facility Evaluation Report and Appeal Rights was provided to the Administrator/ Ariella Bebbassat.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2023
LIC809 (FAS) - (06/04)
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