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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607196
Report Date: 08/16/2023
Date Signed: 08/16/2023 03:50:43 PM


Document Has Been Signed on 08/16/2023 03:50 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:BRENTWOOD ON SUNSETFACILITY NUMBER:
197607196
ADMINISTRATOR:SAM MAGHAZEIFACILITY TYPE:
740
ADDRESS:11580 SUNSET BLVD.TELEPHONE:
(310) 472-4316
CITY:LOS ANGELESSTATE: CAZIP CODE:
90049
CAPACITY:6CENSUS: 2DATE:
08/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:SAM MAGHAZEITIME COMPLETED:
04:33 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
On 08/16/2023 Licensing Program Analyst (LPA) David España conducted an unannounced required annual visit. Upon arrival at the facility, LPA David España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA David España verified that the facility has an approved mitigation plan report.

The facility is licensed for six (6) non-ambulatory residents, of which one (1) may be bedridden and an approved hospice waiver for two (2) residents. Currently, there is one resident on hospice present during today’s visit. LPA met with the administrator, and both toured the inside and outside grounds of the facility. During the tour, LPA observed the facility’s infection control practices. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is in the back patio. LPA observed required postings at the front of the facility. The facility has one out of two residents with memory care needs.

Potentially dangerous items, including sanitizers, are kept inaccessible to residents with dementia. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Furniture in the common area were in good repair. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. The water temperature measured between 105F-120F. A comfortable temperature was maintained in the facility. 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 residents in care. One fire extinguisher was observed in the kitchen area.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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 5


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: BRENTWOOD ON SUNSET
FACILITY NUMBER: 197607196
VISIT DATE: 08/16/2023
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
26
27
28
29
30
31
32
Outside grounds were toured. LPA observed a cascading pond in the backyard of the facility. The widest part of it is about 5 feet and the length is about 8 feet. The pond is about 2 feet deep with water that is inaccessible to residents in care. Pond was gated with hard wired. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

There were deficiencies cited during this visit.

Staffing - Technical Assistance: 1569.618(c)(3) - LPA David España and Licensee/Administrator, Sam Maghazei observed that renewed CPR training for staff was required at the time of visit on 08/16/2023.
Resident Rights/Information - Type B: 87468(c)(2)(A) - LPA David España and Licensee/Administrator, Sam Maghazei observed that there was no PUB 475 at the front entryway of the facility at the time of visit.
Disaster Preparedness - Type B: 1569.695(a) - LPA David España and Sam Maghazei, Administrator observed that the emergency and disaster plan is outdated and not current as of 08/16/2023.



One technical advisory was discussed with Administrator.

An exit interview was conducted, and a copy of this report and appeal rights was provided to Licensee/Administrator, Sam Maghazei.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/16/2023 03:50 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: BRENTWOOD ON SUNSET
FACILITY NUMBER: 197607196

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

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. LPA David España and Licensee/Administrator, Sam Maghazei observed that there was no PUB 475 at the front entryway of the facility at the time of visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
1
2
3
4
The administrator/licensee agreed to have PUB 475 for residents ensuring resident safety. The licensee shall submit
plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of records shall update the
resident's/staff's a written in services plan within 08/25/2023.

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 CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 08/16/2023 03:50 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: BRENTWOOD ON SUNSET
FACILITY NUMBER: 197607196

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA David España and Sam Maghazei, Administrator observed that the emergency and disaster plan is outdated and not current as of 08/16/2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
1
2
3
4
The administrator/licensee agreed to have emergency and disaster plan for residents ensuring resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of records shall update the resident's/staff's a written in services plan within 08/25/2023.
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 CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5