197606459-12-10-2021-11-AS-TAGD-C9KSDK-20211210124716

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606459
Report Date: 12/10/2021
Date Signed: 12/10/2021 12:47:55 PM

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:	WESTWOOD MANOR		FACILITY NUMBER:	197606459
ADMINISTRATOR:	NELLI KHLEBNIKOVA		FACILITY TYPE:	740
ADDRESS:	1539 MIDVALE AVE		TELEPHONE:	(323) 401-8622
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90024
CAPACITY:	6	CENSUS: 6	DATE:	12/10/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:08 AM
MET WITH:	Caregiver, Levan Gocholeishvli		TIME COMPLETED:	01:00 PM

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On 12/10/2021, Licensing Program Analyst (LPA) Troy Agard conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival at the facility, LPA Agard met with Caregiver, Levan Gocholeishvli and conducted a risk assessment on the facility front porch. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for six (6) non-ambulatory and one (1) approved hospice waiver. Currently, there are no hospice residents present during today’s visit.

LPA met with Caregiver, Levan Gocholeishvli and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log. PPE supplies are readily available to staff, and additional supplies are stored; sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is at the front patio. LPA observed staff, and residents maintain 6 feet physical distancing, and each staff person wearing a face covering. LPA observed required postings throughout the facility.

All rooms (6) were inspected. Each room is a single occupancy and has the ability to isolate if needed. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

There are no security bars or weapons on the premises. Resident bathrooms (3) were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. The water temperature measured at 108 F. A comfortable temperature was maintained in the facility.

Cont. 9099

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WESTWOOD MANOR	FACILITY NUMBER: 197606459
	VISIT DATE: 12/10/2021

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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage cabinet. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. The First Aid kit was available. One fire extinguisher was observed in the kitchen area and two others in the hallway.

Outside grounds were toured, no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

No deficiencies were cited during this visit.

No advisory/technical assistance were issued.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

LIC809 (FAS) - (06/04)

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