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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603601
Report Date: 01/17/2023
Date Signed: 01/17/2023 03:48:51 PM


Document Has Been Signed on 01/17/2023 03:48 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:BEVERLY HILLS LOVING CAREFACILITY NUMBER:
197603601
ADMINISTRATOR:LIDA ZARAFSHANFACILITY TYPE:
740
ADDRESS:1019 S. WOOSTER STREETTELEPHONE:
(310) 652-3555
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:176CENSUS: 82DATE:
01/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Adminstrators, Ilana Yazdi and Lida ZarafshanTIME COMPLETED:
04:00 PM
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On 1/17/2023 Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced case management visit to the above facility. LPA met with Manager, Ilana Yazdi and Administrator Lida Zarafshan and explained the purpose of today’s visit was to conduct case management for the incident that occurred on 1/15/2023.

LPA and Manager, Ilana Yazdi toured the physical plant to ensure no health and safety risks were present. The following documents were requested: Facility Roster, Staff Roster Public Health Inspection Report and R#1-R#6; Identification and Emergency Information, Admission Agreement, Physician Report for Community Care Facilities, Appraisal/Needs and Services Plan and Unusual Incident/Injury Reports.
LPA observed room #226 had fire damaged other rooms were not effected by the fire. Resident in room #226 was relocated due to fire damage in room. Residents in rooms #206, #216, #222, #222, #216 and #228 were relocated (vacant rooms) for one(1) night to remove water delivered by automatic sprinklers in the facility. Resident in room #210 was relocated due to health assessment.



No deficiencies cited, exit interview was conducted, a copy of this report is being provided to Administrator, Lida Zarafshan.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
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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