197608888-7-1-2026-11-AS-EDAT-DVKV5R-20260701160823

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608888
Report Date: 07/01/2026
Date Signed: 07/01/2026 04:08:55 PM

Document Has Been Signed on 07/01/2026 04:08 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 LP		FACILITY NUMBER:	197608888
ADMINISTRATOR/ DIRECTOR:	AZUCENA REYES SERRANO		FACILITY TYPE:	740
ADDRESS:	6050 W PICO BLVD		TELEPHONE:	(323) 653-5565
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY: 136		CENSUS: 90	DATE:	07/01/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:58 AM
MET WITH:	Azucena Reyes		TIME VISIT/ INSPECTION COMPLETED:	04:29 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 June 1, 2026, Licensing Program Analyst (LPA) Ernand Dabuet and (RA) Retired Annuitant Nicol Wesley conducted an unannounced annual inspection at the facility using the CARE tool. Upon arrival, they were greeted by Azucena Reyes, the Administrator, and Melanie Heard, the Resident Care Director, andexplained the purpose of the visit. The facility is licensed to serve 136 adults aged 60 and over, with a capacity specifically for 136 non-ambulatory residents. Additionally, the facility holds a hospice waiver for 30 residents. Currently, 90 residents live in the facility. The facility is a three-story commercial building. The first floor includes a parking structure, a laundry room, a maintenance office, an administrative office, and a kitchen. Residents occupy the second and third floors. On the second floor, there are two activity rooms and two shaded outdoor patios. The third floor features a dining/activity room and a medication room. The Department, along with Azucena Reyes, conducted a thorough tour of the physical plant, both inside and outside. There were no bodies of water or obstructions present on the premises. The Department and Azucena Reyes inspected rooms #201, #221 and #231 on the second floor, as well as bedrooms #307, and #318 and #324 on the third floor. All the bedrooms had the necessary furniture in good condition, along with bed linens and adequate closet and drawer space to comfortably accommodate each resident. The walls and floors within the facility were observed to be well maintained. Each inspected bedroom featured its own bathroom, which the Department found to be clean, operational, and compliant with Title 22 regulations. The water temperature was properly measured between 113.0°F and 115.2°F. The Department noted that the facility was clean, appropriately furnished, and had clear passageways both inside and outside. Additionally, a comfortable temperature was maintained throughout the facility. Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WEST PICO TERRACE ASSISTED LIVING CENTER LP	FACILITY NUMBER: 197608888
	VISIT DATE: 07/01/2026

NARRATIVE

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The commercial kitchen was inspected and found to have a sufficient supply of both perishable and non-perishable food, which was maintained in adequate condition. Sharps, toxins, cleaning solutions, and hazardous materials were securely locked away and inaccessible to residents.

Medications were also kept locked in the Medication Room on the third floor, ensuring they were out of reach of residents. Medication Administration Records were audited and found to be maintained in order and complete.

An audit of Resident #1-#6 (R1-R6) service files and Staff #1 - #6 personnel files. The facility has a current liability insurance coverage policy #AES1206745 The facility has a current administrator's certificate on for Azucena Reyes Serrano #6074172740 valid 02/14/2025 through 02/13/2027.

All exits and walkways throughout the facility were clear of debris and hazards. The hardwired smoke detectors and carbon monoxide detectors were functioning properly, and all fire extinguishers in the facility were fully charged. Additionally, the facility is equipped with a landline telephone located in both the office and hallway. Evacuation chairs were available in the stairwells. The last Fire Drill was conducted on 06/19/26.

During the visit, the Department observed the facility's infection control practices, which included screening protocols for visitors, staff, and clients. There were sanitizing stations in common areas and restrooms, and all mandated infection control posters were displayed.

The Department observed the following deficiencies:

Room #230, #307 and #324 with hazardous, toxic chemical items accessible to residents in care.

An exit interview was conducted with Azucena Reyes, the Administrator, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/01/2026 04:08 PM - It Cannot Be Edited

Created By: Ernand Dabuet On 07/01/2026 at 03:22 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: 07/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation], the licensee did not comply with the section cited above. LPA Dabuet identified in rooms #230, #307 and #324 disinfectant spray, gas fluid, and clorox powder. This violation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2026
	Plan of Correction
1 2 3 4	Licensee shall ensure the health and safety at all times of resident in care and to ensure that all toxic and hazardous solutions are stored away from residents in care. Proof of correction must be completed and submitted by POC date to LPA Dabuet ernand.dabuet@dss.ca.gov *Corrected during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:

	Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

LIC809 (FAS) - (06/04)

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