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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608840
Report Date: 03/29/2022
Date Signed: 03/29/2022 06:15:34 PM


Document Has Been Signed on 03/29/2022 06:15 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:BEVERLY HILLS SENIOR CAREFACILITY NUMBER:
197608840
ADMINISTRATOR:ANNIE JIANGFACILITY TYPE:
740
ADDRESS:1015 S. ORANGE GROVE AVENUETELEPHONE:
(323) 933-8271
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:45CENSUS: 38DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Pat DufrenneTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Pat Dufrenne and explained the purpose of today's visit.

This is an RCFE with a capacity of 45. The facility is licensed to serve 45 non-ambulatory residents, ages 60 years and over and a hospice waiver for 20. The following was inspected and toured: 6 resident bedrooms which all have private restrooms, lobby, recreation room, Kitchen, Dining hall, laundry room, medication room, storage area, and office.

The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms and hallways.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Residents are able to use their private accommodations as isolation rooms if they have private rooms and if residents have shared rooms there are designated rooms to be used as isolation rooms if a COVID-19 positive case should arise.
  • 30 day supply of medication for residents
  • Facility has an adequate amount of PPE and facility has enough PPE for 14+ days.
  • Residents were socially distanced according to local public health guidelines.
  • Residents wearing masks.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed (including paper goods, utensils etc).
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS SENIOR CARE
FACILITY NUMBER: 197608840
VISIT DATE: 03/29/2022
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  • Residents temperature is checked and logged once a day.
  • Staff temperatures are checked and logged once a day upon start of shift.
  • Surveillance testing is conducted once every 2 weeks.
  • Mass testing is conducted weekly if there is a positive case in the facility.



According to the California Code of Regulations, LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator Pat Dufrenne and copy of report provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC809 (FAS) - (06/04)
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