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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608888
Report Date: 06/30/2023
Date Signed: 06/30/2023 01:21:14 PM


Document Has Been Signed on 06/30/2023 01:21 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:WEST PICO TERRACE ASSISTED LIVING CENTER LPFACILITY NUMBER:
197608888
ADMINISTRATOR:CHRISTOPHER,MELISSAFACILITY TYPE:
740
ADDRESS:6050 W PICO BLVDTELEPHONE:
(323) 653-5565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:136CENSUS: DATE:
06/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Robin OwensTIME COMPLETED:
01:30 PM
NARRATIVE
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On 629/2023 Licensing Program Analyst (LPA) Felisa Shirley conducted a Case Management visit to follow up on an incident report faxed to CCLD on 6/28/2023. LPA was greeted by Robin Owens, Resident Director. LPA spoke with Robin and explained the purpose of the visit was to gather information surrounding the incident with R1.

The regional office received a copy of an incident report submitted by the facility on 6/28/2023 reporting that on 6/27/2023 Resident 1 (R1) attempted suicide. The incident report stated that on 6/27/2023 at 5:30pm a caregiver went to deliver resident dinner and found them on the floor of the room. First aid was applied and 911 was called. R1 was responsive and was transported to the hospital.

LPA interviewed Administrator, S1 and S2. LPA requested and received copy of list of medications. The following documents were requested and not received during the visit as the forms were not accessible to Staff: ID and Emergency Informational Capability Assessment, Pre-Placement Appraisal. LPA did receive copy of list of medications. Please fax or email requested documentation to me asap.

Deficiencies are being cited based on records review and interviews conducted in accordance with the California Code of Regulations, Title 22, Divisions 6 chapter 1, see LIC 809D. .

An exit interview was conducted, Plans of Corrections were discussed and a copy of this report and appeals rights were and left with Staff, Robin Owens whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa ShirleyTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
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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Document Has Been Signed on 06/30/2023 01:21 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
HSC
87405(a)

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(a) when the administrator is not in the facility, there shall be coverage by a designated substitute who shall have the qualifications adequate to be responsible and accountable for management and administratin of the facility as specified in this section.

This requirement is not met as evidenced by:
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Licensee will submit an LIC308: Designation of facility responsibility form for S1 or appropriately trained staff as a back up administrator to CCLD via fax or email by POC due date.
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Based on records review, the facility does not have documentation making S1 as a designated substitute for the administrator. This is a potential health and safety risk to residents in care.
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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: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa ShirleyTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
LIC809 (FAS) - (06/04)
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