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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608200
Report Date: 12/05/2024
Date Signed: 12/05/2024 02:40:49 PM

Document Has Been Signed on 12/05/2024 02:40 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:ALTA VISTA GARDENSFACILITY NUMBER:
197608200
ADMINISTRATOR/
DIRECTOR:		STACI MARMERSHTEYNFACILITY TYPE:
740
ADDRESS:829 NORTH ALTA VISTA BLVD.TELEPHONE:
(323) 937-1940
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 70CENSUS: 70DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Staci MamershteynTIME VISIT/
INSPECTION COMPLETED:
03:15 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 12/05/24, 8:30 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced annual inspection of the Facility. LPA met with Facility Administrator, Staci Mamershteyn, and reason for the visit was disclosed.

Facility is licensed as a two story building. Fire clearance issued for fifty (50) non-ambulatory, and twenty (20) ambulatory, for total capacity of seventy (70) residents. Bedridden cleared six (6) residents. Hospice waiver approved for six (6) residents.

At 9:05 am, LPA conducted a tour of the physical plant with the Administrator and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Facility provides dementia care; LPA observed delayed egress system working properly throughout all access points of the facility.
Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Wall thermostat displays a setting of 71.0°F, within the required range. Facility maintains an approved Mitigation and Infection Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted September, 2024.

Fire Detection/Protection system is present in the facility. Smoke and carbon monoxide detectors are hardwired, interconnected and tested as "passed" inspection by Los Angeles Fire Department on 03/22/2024. Fire Extinguishers are located throughout the facility. (service date: October 31, 2024) Evacuation routes are clearly posted throughout the facility. Fire drill conducted September 09, 2024.

[LIC809C-Continued]
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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 4
Document Has Been Signed on 12/05/2024 02:40 PM - It Cannot Be Edited


Created By: Raymond Comer On 12/05/2024 at 02:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALTA VISTA GARDENS
FACILITY NUMBER: 197608200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in six out of six resident record files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
1
2
3
4
Administrator agrees to complete reappraisals on residents R1 through R6 by POC date of 12/13/2024. Additionally, administrator agrees to create a calendar of when each residents reappraisal needs to be completed to ensure that reappraisals are completed as required.
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:Eva Miller
LICENSING EVALUATOR NAME:Raymond Comer
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
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: ALTA VISTA GARDENS
FACILITY NUMBER: 197608200
VISIT DATE: 12/05/2024
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
Kitchen: At 9:50 am, kitchen was observed to be clean and an adequate supply of perishables and non-perishable food located in multiple commercial refrigerators, freezer, and pantry. Food was properly labeled and stored. Emergency food is stored in sub floor area adjacent to the laundry room. Trash cans observed with lids. Sharps are stored in the kitchen and inaccessible to residents. No pesticides, nor poisons, were observed near any food areas.

Medications: Medication room is located on first floor, near the building entrance. Medication room observed to be locked when unattended by staff. Medications are stored in separate compartments,by resident name. PPE, first aid kit, and manual stored in the medication office. LPA observed medications as prepared and dispensed to residents by medical technician staff.

Laundry: At 10:20 am, LPA observed laundry room, located on the sub-base level floor, to be clean and clear from obstruction. Commercial laundry machines were observed to be in operating condition and inaccessible to residents. Laundry soap, toxins, and poisons observed to be locked and stored in basement area supply cabinet.

Commons: At 10:35 am, LPA observed activities room, and dining room, located on the first floor. Outside patio area and surrounding area of the facility observed to be clean and clear from debris and obstruction. All common areas observed to have sufficient tables and chairs for seating.

Bedrooms At 11:15 am, LPA observed random bedrooms, with bathrooms, located on the first and second floor to be appropriately furnished with sufficient lighting, bed linen and comforters on all beds. Bedrooms contain single and double occupancy. All bedrooms observed to be clean and clear from obstruction.

Bathrooms: At 11:15 am, LPA observed random bathrooms, located in the bedrooms on the first and second floor. LPA observed appropriate grab bars and non-slip skid flooring in the bathtub. Hot water temperature measured in range from 109.2°F through 115.5°F; within the required range. Bathrooms observed to be clean and have sufficient soap and hand towels are not shared.



Resident records: At 12:05 pm, Facility records room observed as locked and inaccessible to residents. A total of six (6) resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. LPA review of record revealed residents (R1) through (R6) reappraisal/needs and services plans were not updated within twelve (12) month period, as required.

[LIC809C-Continued]
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ALTA VISTA GARDENS
FACILITY NUMBER: 197608200
VISIT DATE: 12/05/2024
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
Staff records: Facility records room was observed as locked and inaccessible to residents. A total of four (4) Staff files were reviewed. Criminal record clearances were present, and Staff are associated to this facility. Staff records appear to be complete and current.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D).

Exit Interview Conducted, appeal rights discussed, and copy of the report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4