<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606597
Report Date: 05/22/2023
Date Signed: 05/22/2023 11:42:44 AM


Document Has Been Signed on 05/22/2023 11:42 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:WESTPORT HOMEFACILITY NUMBER:
197606597
ADMINISTRATOR:REX RETOLADOFACILITY TYPE:
740
ADDRESS:10252 EAST AVENUE STELEPHONE:
(661) 944-5779
CITY:LITTLEROCKSTATE: CAZIP CODE:
93543
CAPACITY:20CENSUS: 0DATE:
05/22/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rex RetoladoTIME COMPLETED:
11:45 AM
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
The purpose of this meeting was to discuss issues of non-compliance with their closure plan pursuant Health and Safety Code 1569.682 and the Administrators’ participation in the facility closure, resulting in inappropriate transferring of residents.

Present at today’s meeting:


Rex Retolado, Administrator
Angela Kendrick, Regional Manager (RM)
Eva Miller, Licensing Program Manager (LPM)
Michael Cava, Licensing Program Manager (LPM)
Evelin Rios Licensing Program Analysts (LPA)
Ginger Perini, Regional Director Wise and Healthy Aging Long Term Ombudsman (LTCO)

The informal conference process was explained to the Administrator.

During today’s conference, the following matters were discussed:

· Closure Plan

· Administrative qualifications and duties

· Personal Rights of the residents in care

Pursuant to Title 22, Division 6, Chapter 8, the following citations issued on the 809D. In addition, Rex was advised to submit the following information by Close of Business 05/23/23 to LPA Rios.

· New resident list from Rex to confirm where residents are currently located.

· LIC621 Client/Resident Personal Property and Valuables


SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 05/22/2023 11:42 AM - 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: WESTPORT HOME
FACILITY NUMBER: 197606597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2023
Section Cited
HSC
1569.682(a)(2)

1
2
3
4
5
6
7
§1569.682 Transfer of resident upon forfeiture of license or change in use of facility; duties of licensee; closure plan; (a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility or to an independent living arrangement as result
1
2
3
4
5
6
7
As POC, the administrator will still submit a proper closure plan compliant to section 1569.682 . Closure plan is due by close of business to the licensing agency 05/23/23
8
9
10
11
12
13
14
of the forfeiture of a license, steps to transfer affected residents safely and to minimize possible transfer trauma...
This requirement is not met as evidenced by:
Based on administrator admission residents were not provided a proper 60 day notice as licensee intended to close faciilty.
8
9
10
11
12
13
14
Type B
05/23/2023
Section Cited
CCR87405(d)

1
2
3
4
5
6
7
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
As POC, the administrator will read this section of the regulation, and self certify that he has revewied and understood section 87405(d). Self certification is due to the licensing agency by close of business 05/23/23.
8
9
10
11
12
13
14

Based on administrator admission there was evidence administrator failed to demonstrate knowledge and or ability to perform applicable laws, rules and regulations when providing a closure plan.
8
9
10
11
12
13
14
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/22/2023 11:42 AM - 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: WESTPORT HOME
FACILITY NUMBER: 197606597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2023
Section Cited
CCR
87468.1(a)(2)

1
2
3
4
5
6
7
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will provide LPA a new residents list of resiednts current locations by close of business 05/23/23.
8
9
10
11
12
13
14
Based on Informal Meeting with the administrator, the administrator could not confirm where most residents were relocated to.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3