197608888-1-23-2023-11-AS-PBUR-CNCQQ8-20230123112154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608888
Report Date: 01/20/2023
Date Signed: 01/23/2023 11:21:59 AM

Document Has Been Signed on 01/23/2023 11:21 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	WEST PICO TERRACE ASSISTED LIVING CENTER LP		FACILITY NUMBER:	197608888
ADMINISTRATOR:	CHRISTOPHER, MELISSA		FACILITY TYPE:	740
ADDRESS:	6050 W PICO BLVD		TELEPHONE:	(323) 653-5565
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	136	CENSUS: 60	DATE:	01/20/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Vladimir Kaplun		TIME COMPLETED:	04:45 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	Licensing Program Analysts (LPAs) Pamela Bunker, Ernand Dabuet, Lourdes Montoya, and Martessa Brown made an announced visit and met with Applicant Vladimir Kaplun to conduct a Pre-Licensing evaluation change of ownership from Country Villa Terrace Assisted Living Center #198201010 to West Pico Terrace Assisted Living Center #197608888. An application was submitted to Community Care Licensing Department (CCLD) on June 28, 2015, for an initial application for Residential Care Facility for the Elderly (RCFE) for ages 60 years and older. The requested capacity is for 136 non-ambulatory clients. There are currently 60 residents in placement. The facility is a three-story commercial business building. LPA Dabuet reviewed the resident's records. LPAs, Bunker, Montoya, and Brown inspected resident rooms and common areas on all three (3) floors. The roof is accessible through one of the two (2) stairwells. The door is alarmed. Grab bars were properly installed in all resident restrooms. The signal system is activated by a push-button chord in the resident bedrooms. This goes directly to a board in the dining area where a desk is set up for staff to monitor. The system was tested randomly from rooms on both resident floors and the response time was less than a minute. Floors level two (2) and three (3) are occupied by residents and the ground floor contains the parking structure, laundry room, beauty salon, maintenance office, administrative office, activity office, kitchen, mini kitchen, main dining/activity room, mini dining room, medication room, nursing office, duet studios, and rehabilitation center. There is skilled nursing attached to this building that shares the kitchen and beauty salon. The Rehabilitation section is used by skilled nursing only. There are activity rooms on both resident floors. The facility dining room/activity room and commercial kitchen were inspected. The facility has adequate perishable and nonperishable food and water supplies. The facility has an emergency generator permit. See continued LIC809-C page 2

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WEST PICO TERRACE ASSISTED LIVING CENTER LP	FACILITY NUMBER: 197608888
	VISIT DATE: 01/20/2023

NARRATIVE

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Continued LIC809-C page 2

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcases, mattress paddings, fitted sheets, blankets, and bedspreads. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted and readily available for review in the hallway. The menu is located in the dining room on the third (3rd) floor. The facility has a landline telephone located in the office and hallway. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked cabinet. Smoke Detectors/Carbon Monoxide(s): The facility has hardwired battery-backup carbon monoxide and smoke detectors located in the bedrooms, hallway, and throughout the facility are operable. There are charged fire extinguishers located throughout the facility. Appliances: Refrigerator, stove burners (gas), microwave, and washer/dryer are in working and in operable condition. The facility is equipped with central air and heat Toxins: Cleaning supplies and toxins are locked and stored in the laundry room and janitor supplies closet only accessible to staff. Water Temperature: Hot water temperature was tested on all floors between 105 to 116.9 degrees Fahrenheit. Medication, First-Aid Kit, and Manual: Medications are kept on the third (3rd) floor in the Medication room. Medication procedures were reviewed. Sufficient bandages, tweezer, thermometer, and scissors. The first aid kit is fully stocked with a manual. Client & Staff Files: Designated area for files will be located in a locked file cabinet located in the facility office. The applicant will handle the resident's cash resources in the facility office and kept in a locked safe. Pools/Jacuzzi & Pets: No bodies of water and no pets on the premises. Fire Clearance: Fire clearance was approved on 01/26/2015.

**See continued LIC 809-C page 3 for the continuation of this report**

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WEST PICO TERRACE ASSISTED LIVING CENTER LP	FACILITY NUMBER: 197608888
	VISIT DATE: 01/20/2023

NARRATIVE

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Continued LIC 809-C page 3

The following correction required before licensure:

Non-Associated Staff:
Staff 1-2 (S1-S2) did not have a signed Criminal Background Clearance Transfer Request, LIC 9182.

Smoke Detectors:
Smoke detectors in bedrooms #201 and #207 are broken.

Fire Extinguishers:
Two fire extinguishers on the 2nd floor and 3rd floor in the hallway are breaking away glass is missing.

Physical Plant:
The screen door in resident bedroom #214 is not properly working. The carpet is dirty on the stairs between the second floor and third floor, resident bedroom #334, and in the hallway on the second floor.
The bathroom in resident bedroom #211 has no exhaust fan and the bottom wall in the bathroom is scraped out and molded. There are no chairs in resident bedrooms #207, #216, and #218.

Bathrooms:
All bathrooms do not have hand washing posters; there are no skid mats in resident bathrooms # 201, #207, #208, and #220. Bathrooms Toilets not working on the 2nd-floor bathroom #201 was missing a cover and the toilet wasn’t working, #209 water doesn’t turn off and the toilet was not working and #212 toilet was not working. Carpets leading in bedrooms room 333 and 334 were dirty with stains and unsanitary.

Bedrooms:
Rooms #217 and #315 are cluttered.

An exit interview was conducted, and a copy of this report has been furnished to the applicant.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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