197609048-8-15-2024-11-AS-WGIS-D86TNM-20240815145258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609048
Report Date: 08/15/2024
Date Signed: 08/15/2024 02:53:05 PM

Document Has Been Signed on 08/15/2024 02:53 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, 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: 6	DATE:	08/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:	Serguei Kalistratov		TIME COMPLETED:	03:15 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 08/15/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Care Provider, Genevieve Librando, and the purpose of today’s visit was explained. We were later joined by Licensee/Administrator Sergue Kalistratov and Staff, Irina Fried. The facility is licensed to serve six (6) non-ambulatory residents over the age of 60 with an approved hospice waive for two (2) residents. Physical Plant/Structure 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, outside shaded area, indoor and outdoor activity area, laundry room and a detached garage. LPA did not observe any bodies of water on the premises. All walkways around the home were observed to be clean, clear, and free of debris, obstructions, and hazards. Bedrooms LPA inspected all resident rooms and observed the walls and floors to be in good repair. LPA observed all resident rooms had the required furniture including a bed, dresser, nightstand, storage space for personal belongings, and ample lighting. LPA observed all beds had the required linens including a mattress cover, fitted sheet, blanket, comforter, and pillows. LPA observed an ample supply of bed linens, and blankets at the time of visit. Beds and bedding were in good condition.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLYWOOD RETIREMENT HOME	FACILITY NUMBER: 197609048
	VISIT DATE: 08/15/2024

NARRATIVE

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Bathrooms LPA inspected the facility bathrooms and found them to be within Title 22 regulations. All bathrooms were observed clean and operational. LPA observed storage area for personal hygiene products. LPA observed an ample supply of towels and personal hygiene products available for residents. All showers had a nonskid mat, shower chair, and secured safety handrails. The water temperature measured 105.4-degrees, 105.2-degrees, and 106.3-degrees Fahrenheit.
Kitchen LPA inspected the kitchen and observed it to be clean and sanitary. LPA observed all appliances to be operable and in good repair. LPA observed an ample supply of dishware, cookware, and cutleries. LPA observed a 2-day supply of perishable foods and a 7-day supply of non-perishable foods properly stored and labeled. The water temperature measured 106.7-degrees Fahrenheit. All sharps are secured in a locked drawer and are inaccessible to residents. All cleaning supplies are secured in a locked cabinet in the laundry room and are inaccessible to residents.
Common Rooms LPA observed the facility to be appropriately furnished during the time of visit. The facility has a living room with recliners to accommodate all residents. The dining room table is large enough to accommodate residents for meals. LPA observed all walkways and hallways in the facility to be clean, clear, and free of hazards and obstructions. All rooms were observed with ample lighting. The facility was kept at a comfortable temperature.
Safety LPA observed two (2) fully charged fire extinguisher located in the laundry room and in the hallway, last serviced on 04/17/24. All smoke and carbon monoxide detectors are operable. The last Fire Prevention Inspection conducted by the local Fire Department was conducted on 04/17/24. The last emergency drill

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLYWOOD RETIREMENT HOME	FACILITY NUMBER: 197609048
	VISIT DATE: 08/15/2024

NARRATIVE

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was conducted on 07/01/24. All exits are marked with an EXIT sign. All exits were observed clear of obstructions. LPA reviewed the facility’s Emergency and Disaster Plan. LPA inspected the First Aid kit and observed it had the required items and a current manual. LPA observed all required documents posted in the facility. The facility has a working landline telephone. There are no firearms are ammunition stored at the facility.
Medication LPA observed all Centrally Stored Medications secured in a locked cabinet, in the dining room, and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the medications and Centrally Stored Medication Logs for three (3) residents, medications are documented properly and provided as prescribed.
Infection Control Upon entry, LPA observed a sanitizing station and visitor sign-in log. LPA observed on the table there is hand sanitizer, thermometer, and masks available. LPA observed all required Infection Control signs posted in the facility. LPA observed a 30-day supply of Personal Protective Equipment (PPE).
File Review LPA reviewed the files for four (4) residents and observed they had the required documents. LPA reviewed the administrator and two (2) staff files and found they contained the required documents, certification, and training. The administrator’s Administrator Certificate is valid till 08/21/25. LPA received and reviewed a copy of the facility Liability Insurance through Acord valid till, 10/10/24. Licensing fees are current.
LPA did not observe or cite any deficiencies.
An exit interview was conducted with Staff, Irina Fried, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

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