197603601-2-6-2023-11-AS-DESA-CNSSXC-20230206131543

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603601
Report Date: 02/06/2023
Date Signed: 02/06/2023 01:16:03 PM

Document Has Been Signed on 02/06/2023 01:16 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 LOVING CARE		FACILITY NUMBER:	197603601
ADMINISTRATOR:	LIDA ZARAFSHAN		FACILITY TYPE:	740
ADDRESS:	1019 S. WOOSTER STREET		TELEPHONE:	(310) 652-3555
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	176	CENSUS: 82	DATE:	02/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lida Zarafshan		TIME COMPLETED:	01:30 PM

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) David Espana and Licensing Program Analyst (LPA) Antonine Richard, and Licensing Program Analyst (LPM) Ulysses Coronel conducted an unannounced Annual required visit with a primary focus on infection control measures. LPAs and LPM was met by Ilana Yazdi, Controller, and the purpose of today’s visit was explained. The facility is licensed to serve 176 residents 64 non-ambulatory and 5 bedridden in room # 104, #106, #108, #118 and #128. There are currently 82 residents in placement total. Wooster Building: consists of 50 resident bedrooms w/ private bathrooms, dining room, kitchen, activity rooms. and an underground garage. Olympic Building: consists of 62 resident bedrooms w/ private bathrooms, dining room, kitchen, activity rooms. and an underground garage. LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair, except for bedrooms number 226 and 230 which had damage due to recent fire incident. Beds had a Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. During today visit 2/6/23 team observed room 109 water temperature at 123.5F and room 127 water temperature at 125.4F. In building Wooster, A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is not enough non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

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 LOVING CARE	FACILITY NUMBER: 197603601
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in During today visit 2/6/23 team observed room 109 water temperatue at 123.5 and room 127 water temperature at 125.4: In building Wooster which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/07/2023
	Plan of Correction
1 2 3 4	Admin. will craete a plan of corrections on 2/7/2023 to insure hot tem. will be maintained between 105-120 f. and prof of correction will be made to LPA Espana

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	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/06/2023 01:16 PM - It Cannot Be Edited

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 LOVING CARE	FACILITY NUMBER: 197603601
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. 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 in: Patio door windown screen was missing in socail activities room was missing and window screens missing in room 132 and 130 room was missing: Olypmic building which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/20/2023
	Plan of Correction
1 2 3 4	The Admin. agreed to have repairs done and plan of correction will done within two weeeks 2/20/23, and submitted to LPA David Espana.

Type B

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. 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 in: Today LPA Espana did view the have supplies of nonperishable foods for a minimum of one week in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2023
	Plan of Correction
1 2 3 4	The Admin. argreed to submit a plan of corection, and show that the correction will be provided, and that nonperishable expired date will be trashed. And, proff of correction will be submitted to LPA David Espana by Friday 2/10/2023.

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	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

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 LOVING CARE	FACILITY NUMBER: 197603601
	VISIT DATE: 02/06/2023

NARRATIVE

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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were deficiencies observed, Title 22 Regulations are being cited, please LIC809D.

Exit interview held, and plans of corrections developed. A copy of the report and appeals was provided to LIDA ZARAFSHAN, Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC809 (FAS) - (06/04)

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