197607606-1-27-2022-31-AS-JGTN-CB3USU-20220127145054

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607606
Report Date: 01/27/2022
Date Signed: 01/27/2022 02:51:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	NIKKEI SENIOR GARDENS		FACILITY NUMBER:	197607606
ADMINISTRATOR:	DESIREE KITAGAWA		FACILITY TYPE:	740
ADDRESS:	9221 ARLETA AVE		TELEPHONE:	(818) 899-1000
CITY:	ARLETA	STATE: CA	ZIP CODE:	91331
CAPACITY:	106	CENSUS: 74	DATE:	01/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Desiree Kitagawa - Executive Director		TIME COMPLETED:	02:28 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) Gary Tan, met with Executive Director Desiree Kitagawa for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 10:43 AM and the following were noted: There is only one entrance being utilized at the facility, the front main entrance door. There are required poster posted at the main door. Screening area is located immediately upon entrance. All visitors/resident and staff are required to sign. There is also a sign in sheet, hand sanitizer, gloves and masks available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit. The facility had submitted and approved Mitigation plan. There are hand sanitizing stations all over the facility. There are signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in common bathrooms, elevators and all over the common areas of the facility. The facility has a designated visitors' area in the front entrance and lobby. The facility has sufficient stock of PPE in the storage room. The facility is fire cleared for One hundred six (106) non-ambulatory residents, forty (40) of which may be bedridden. Hospice waiver is approved for ten (10) residents. (continued to LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NIKKEI SENIOR GARDENS	FACILITY NUMBER: 197607606
	VISIT DATE: 01/27/2022

NARRATIVE

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(continued from LIC 809)

Common areas, including the activity room, gym, movie theater, dining room and library appeared clean and were properly furnished. The kitchen appeared clean and the appliances and fixtures functional. Residents do not have access to the kitchen; dangerous items are properly stored and inaccessible to residents. Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. The patios and balconies have proper furnishings. The medications were locked in the medication carts. Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings, working signal system, grab bars and non-skid surfaces in the bathrooms. Hot water temperature in random resident bathrooms were checked and measured a range of 109.9°F to 118.8°F.

Fire extinguishers are located throughout the facility hallways on both floors and were last serviced on 08/05/21. There are First aid kits in the medication room located in the ground floor. The facility's smoke alarms are hard wired and interconnected and back up and tests are done in house on a monthly basis.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC809 (FAS) - (06/04)

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