197608787-6-1-2021-11-AS-SCIS-C3KTYL-20210601150855

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608787
Report Date: 06/01/2021
Date Signed: 06/01/2021 03:10:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	MERIDIAN AT OCEAN VILLA		FACILITY NUMBER:	197608787
ADMINISTRATOR:	SHAWN C MOONEY		FACILITY TYPE:	740
ADDRESS:	413 OCEAN AVE		TELEPHONE:	(310) 393-0242
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90402
CAPACITY:	36	CENSUS: 16	DATE:	06/01/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Christina Harris-Nurse/Administrator		TIME 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 06/01/21, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with administrator Christina Harris and explained the purpose of today’s visit. The facility is an RCFE licensed for thirty-six (36) non-ambulatory, of which (8) may be bedridden and also includes Hospice waiver for (9) nine. Currently, there are (16) non-ambulatory residents residing in the facility, all are over the age of 59 or older. The facility is a two-story structure located in a residential neighborhood. It consists of the following: twenty-nine (29) resident rooms with attached bathroom, lounge, outdoor patio, dining area, kitchen, pantry and laundry room. LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage area cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Smoke detectors were observed in client rooms and are connected to the fire department. Six (6) fully charged fire extinguishers were found throughout the facility. LPA reviewed Medication Administration Record (MAR) and observed it to be maintained in order and accurate. Continued on 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021

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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: MERIDIAN AT OCEAN VILLA	FACILITY NUMBER: 197608787
	VISIT DATE: 06/01/2021

NARRATIVE

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During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff tests and vaccination results will be provided by the licensee by email.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Nurse/Administrator Christina Harris via email.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021

LIC809 (FAS) - (06/04)

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