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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607606
Report Date: 01/19/2023
Date Signed: 01/19/2023 03:14:31 PM


Document Has Been Signed on 01/19/2023 03:14 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:NIKKEI SENIOR GARDENSFACILITY NUMBER:
197607606
ADMINISTRATOR:DESIREE KITAGAWAFACILITY TYPE:
740
ADDRESS:9221 ARLETA AVETELEPHONE:
(818) 899-1000
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY:106CENSUS: 76DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Desiree Kitagawa - Executive DirectorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced One (1) Year Required Infection Control visit to this facility at 9:53 am. LPA met with Desiree Kitagawa, Executive Director and disclosed the purpose of this visit.

LPA conducted a tour of the physical plant at 10:10 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette, and physical distancing) posted. The PPE screening station is located on a table near the entrance equipped with sufficient PPE readily accessible, hand sanitizer, gloves, and sign in sheet at the time of visit.



While conducting a tour of the physical plant LPA observed signs to wear a mask and other Covid 19 prevention protocol signs were posted throughout the facility on both floors as well as hand washing, cough etiquette, and physical distancing signs. Suitable cleaning and disinfecting completed after every visit.
The facility has multiple fire extinguishers located throughout the facility an observed to be charged. Fire safety/Elopement drill performed monthly. The smoke detectors are tested monthly with one annual and based on review of the monthly inspection reports all detectors passed for all apartments.
Bedrooms: At 10:30 am LPA Smith observed ten (10) random bedrooms that are equipped with private bathrooms. All bedrooms observed to be appropriately furnished with sufficient lighting. LPA observed adequate bed linen and comforters on all beds. All bedrooms observed to be clean and clear from obstruction. The facility has public bathrooms located on 1st floor. (Cont to 809-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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: 01/19/2023
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(Cont. from 809)

Bathrooms: At 10:30 am LPA observed ten (10) bathrooms located inside of resident’s rooms to be clean and clear from obstruction. LPA observed grab bars in shower and toilet area or a commode with handles around the toilet area. Bathrooms are stocked and equipped with soap and paper towels. The water temperature range was between 109.8- and 120.4-degrees Fahrenheit. Toxins stored in 1st floor janitors’ area and 2nd floor storage closet observed to be locked an inaccessible to residents in care.

Medications: At 12:47 pm LPA Smith observed Medication Center on 1st floor, to be storing medication carts. Medication carts used for medication were observed to be locked and inaccessible to residents. First aid kits located in the medication center and at lobby desk.

Kitchen: At 1:30 pm LPA observed the kitchen to be clean and free from obstruction and inaccessible to residents. Appliances observed to be in good repair and functioning. The facility has a sufficient 7-day perishable and 2 days non-perishable food.
Dining room/Resident Lounge/Common areas at 10:10 am observed to be adequately furnished with tables and chairs and adequate lighting. LPA observed the areas to be clean and free from debris.

PPEs: Observed PPE storage at 2:50 pm located on 2nd floor to be stocked with a sufficent supply of items.

Outside/Grounds: At 12:15 pm the Outside areas and grounds observed to be free from obstruction. Patio areas observed to be adequately.

No deficiencies cited, exit interview conducted, copy of report given.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC809 (FAS) - (06/04)
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