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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606459
Report Date: 12/05/2024
Date Signed: 12/05/2024 03:48:59 PM

Document Has Been Signed on 12/05/2024 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:WESTWOOD MANORFACILITY NUMBER:
197606459
ADMINISTRATOR/
DIRECTOR:		NELLI KHLEBNIKOVAFACILITY TYPE:
740
ADDRESS:1539 MIDVALE AVETELEPHONE:
(323) 401-8622
CITY:LOS ANGELESSTATE: CAZIP CODE:
90024
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Nelli KhlebnikovaTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Nelli Khlebnikova, Administrator and the purpose of the visit was discussed. Facility is licensed to serve 6 non- ambulatory residents and an approved hospice waiver for 1 resident. None of the residents are diagnosed with dementia or receiving home health or hospice care services at time of visit. The facility does not handle any of the residents’ money.

This home is a single story home consisting of: (6) resident bedrooms, (3) Full bathroom, living room, kitchen with dining room, laundry room (located in the hallway) and an outdoor shaded patio area. LPA toured the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 107 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies:

See 809-C and D

Janae HammondTELEPHONE: (424) 544-1027
Sparkle DayTELEPHONE: (424) 544-1075
DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WESTWOOD MANOR
FACILITY NUMBER: 197606459
VISIT DATE: 12/05/2024
NARRATIVE
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- On 12/5/24 LPA reviewed Staff #2 and Staff #4 records. LPA observed the records are incomplete. Staff #2 and Staff #4 files did not contained the physicians report.

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with, Alisa Nadzina, Administrator Assistant.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/05/2024 03:48 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: WESTWOOD MANOR
FACILITY NUMBER: 197606459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited


This requirement is not met as evidenced by: Staff #2 and Staff #4 did not have Physcian Reports on file at time of visit.
Deficient Practice Statement
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Based on [(observation) and record review)], the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2024
Plan of Correction
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Administrator will send Physican Reports to LPA by POC Date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae HammondTELEPHONE: (424) 544-1027
Sparkle DayTELEPHONE: (424) 544-1075

DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024

LIC809 (FAS) - (06/04)
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