197607606-1-2-2024-31-AS-CALH-CZ537D-20240102165947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607606
Report Date: 01/02/2024
Date Signed: 01/02/2024 05:00:27 PM

Document Has Been Signed on 01/02/2024 05:00 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
WOODLAND HILLS S.RO, 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: 69	DATE:	01/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Executive Director Shin Ito		TIME COMPLETED:	05:00 PM

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On 01/02/2023 at 12:55 PM, Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – Annual Continuation Inspection and met with Executive Director Shin Ito and disclosed the purpose of this visit.

At 01:10 PM LPA Alemoh conducted a physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Facility is licensed to serve elderly residents aged 60 and above. Facility is cleared for 66 non ambulatory and 40 Bedridden residents. Facility is licensed to house separate Dementia wing and delayed egress. Facility is approved the facility also has an approved hospice waiver for 10 (10) residents. The Annual Licensing Fees are current.

Facility has a coded gate. Facility is a two-story building. Parking lot located on the east side of the building and wraps along property.

The Executive Director accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

LPA observed ten (10) Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

LPA observed Ten (10) Resident bathrooms at random. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 106F-118F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPA observed hand washing signs in all restrooms.

Common areas were clean and clear of hazards, doorways were free of obstructions.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024

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

FACILITY NAME: NIKKEI SENIOR GARDENS	FACILITY NUMBER: 197607606
	VISIT DATE: 01/02/2024

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Facility has two laundry rooms; one is designated for staff. Both are equipped with two industrial sized washer/ dryer all appliances, in good working order at time of visit. Cleaning agents secured and inaccessible to residents.

LPA toured the kitchen area and observed a two day supply of perishable and a seven day supply of non-perishable food. Knives were kept in locked secure area locked. Appliances observed to be in good repair and functioning. Toxins stored in 1st floor janitors’ area and 2nd floor storage closet observed to be locked an inaccessible to residents in care. First Aid kit and manual was located near the administrator desk. There are multiple fire extinguishers in the facility. Extinguishers were observed to be charged with receipt dated Oct 1st 2023. Dual Smoke alarms and carbon monoxide are hardwired and interconnected, were tested and observed to be operable. Facility also has a sprinkler system. Fire/earthquake both tested quarterly.

At 2:30 PM LPA conducted a file review.

9 staff records were reviewed, 9 out of 9 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions.

9 resident records were reviewed and, 9 out of 9 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans.

LPA met with Pharmacist Samantha Orduna in the medication room. The room is equipped with industrial sized medication carts, used to disperse resident medications. All med carts were observed to be locked and inaccessible to residents. First aid kits located in the medication center and at lobby desk.

No deficiencies cited.

An exit interview was conducted. A copy of this report and appeal rights were left with Executive Director Shin Ito.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024

LIC809 (FAS) - (06/04)

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