197609048-10-7-2022-11-AS-UCOL-CJYUTZ-20221007155246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609048
Report Date: 10/07/2022
Date Signed: 10/07/2022 03:55:34 PM

Document Has Been Signed on 10/07/2022 03:55 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	BEVERLYWOOD RETIREMENT HOME		FACILITY NUMBER:	197609048
ADMINISTRATOR:	KALISTRATOV, SERGUEI		FACILITY TYPE:	740
ADDRESS:	9014-9016 HARGIS STREET		TELEPHONE:	(310) 838-7743
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY:	6	CENSUS:	DATE:	10/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:09 PM
MET WITH:	Genevieve Librando, staff.		TIME COMPLETED:	04:25 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 Manager (LPM) Ulysses Coronel and Licensing Program Analyst's (LPA) Mario Leon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPM and LPA was met by caregiver Genevieve Librando and spoke to administrator Serguei Kalistratov via telephone and the purpose of today’s visit was explained. The facility is licensed to serve 6 non-ambulatory residents ages 60 and above, hospice waiver for 2. There are currently six (6) residents in placement.. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 6 bedrooms, 3 bathrooms, family room/dining room, kitchen, living room, shaded area, indoor and outdoor activity area, laundry room and a detached garage. LPM, LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 102.5 and 127.5 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LIC 809-C

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 981-3962
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

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 8

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLYWOOD RETIREMENT HOME	FACILITY NUMBER: 197609048
	VISIT DATE: 10/07/2022

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
26
27
28
29
30
31
32

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were deficiencies observed. Title 22 Regulations were cited and Technical assistance notes were provided please see LIC809D and LIC9102.

Exit interview held. A copy of the report was provided to Genevieve Librando, staff.

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 981-3962
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC809 (FAS) - (06/04)

Page: 2 of 8

Document Has Been Signed on 10/07/2022 03:55 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLYWOOD RETIREMENT HOME	FACILITY NUMBER: 197609048
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 during today's visit, LPA Mario Leon observed hot water temperatures in bathroom 1 being 127.5 F, bathroom 2 125.7 F, bathroom 3 120.5 F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/08/2022
	Plan of Correction
1 2 3 4	Licensee will create a plan to ensure that Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). Proof of correction will be submitted to LPA Leon via email at mario.leon@dss.ca.gov.

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.

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 981-3962
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC809 (FAS) - (06/04)

Page: 3 of 8

Document Has Been Signed on 10/07/2022 03:55 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLYWOOD RETIREMENT HOME	FACILITY NUMBER: 197609048
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited LPA Mario Leon observed that all six (6) residents have bed rails attached to their beds. Staff was unable to provide a written order from a physician indicating the need for the postural support maintained in the resident's record, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Licensee will obtain written order from a physician indicating the need for the postural for all six clients, proof of correction will be submitted to mario.leon@dss.ca.gov.

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.

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 981-3962
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC809 (FAS) - (06/04)

Page: 4 of 8

Document Has Been Signed on 10/07/2022 03:55 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLYWOOD RETIREMENT HOME	FACILITY NUMBER: 197609048
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited aboveDuring today's visit LPA Mario Leon observed one (1) rolling tray and one (1) recliner blocking the exit door, located in room #6 and the resident's bed blocking the exit located in room #3. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Licensee will remove rolling tray, recliner and residents bed from indoor passageways in bedrooms 3 and 6 and will create a plan to ensure that all outdoor and indoor passageways and stairways shall be kept free of obstruction. Plan of correction will be submitted to LPA Leon at mario.leon@dss.ca.gov.

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.

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 981-3962
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC809 (FAS) - (06/04)

Page: 8 of 8