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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608888
Report Date: 12/10/2024
Date Signed: 12/10/2024 03:40:07 PM

Document Has Been Signed on 12/10/2024 03:40 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:WEST PICO TERRACE ASSISTED LIVING CENTER LPFACILITY NUMBER:
197608888
ADMINISTRATOR/
DIRECTOR:		CHRISTOPHER,MELISSAFACILITY TYPE:
740
ADDRESS:6050 W PICO BLVDTELEPHONE:
(323) 653-5565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY: 136CENSUS: 78DATE:
12/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Michael Weiss, Administrator of SkilledTIME VISIT/
INSPECTION COMPLETED:
04:00 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 Analyst (LPA) Sparkle Day conducted a unannounced Case Management site visit to the facility to ascertain information pertaining to the Licensee-initiated Unusual Incident/Injury Report submitted to CCLD on 11/22/2024 .LPA Day met with Administrator Michael Weiss and Wellness Coordinator Robin Owens and the purpose of the visit was discussed. LPA spoke with Clarizze Punit , Administrator via phone.

During this visit LPA requested and received the following documents: Staff and resident roster, file for Resident #1, including but not limited to Identification and information sheet, Admisision Agreement, Medical Assessment , Appraisal and Medications list.
LPA interviewed Staff #1 - Staff #5, LPA attempted to interview R#1-R#2, however they would not open the door.
Based on the information gathered and the interviews conducted by the LPA. The LPA finds that According to the California Code of Regulations (Title 22, Division 6, Chapter 8),the following deficiencies were issued and a citation was cited.

See 809-D

An exit interview was conducted and a copy of the Report and Appeal Rights were provided to Robin Owens, Wellness Coordinator..
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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 2
Document Has Been Signed on 12/10/2024 03:40 PM - It Cannot Be Edited


Created By: Sparkle Day On 12/10/2024 at 12:52 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WEST PICO TERRACE ASSISTED LIVING CENTER LP
FACILITY NUMBER: 197608888

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2024
Section Cited
CCR
87468(b)

1
2
3
4
5
6
7
Personal Rights
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature,
1
2
3
4
5
6
7
Administrator agrees to Develop a plan that ensures that Resident #1 rights are not violated and All staff shall attend a training on Personal Rights of the residents in care by the POC date. 12/20/2024
A copy of the training logs and development plan will be sent to LPA :
8
9
10
11
12
13
14
This requirement was not met as evidence by: Staff did not ensure a safe and healthful accommodations for resident in care. Which poses a potential health and safety risk to clients in care
8
9
10
11
12
13
14
Sparkle Day @ Sparkle.day@dss.ca.gov

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Janae Hammond
LICENSING EVALUATOR NAME:Sparkle Day
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2