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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609311
Report Date: 11/16/2023
Date Signed: 12/05/2023 10:53:48 AM


Document Has Been Signed on 12/05/2023 10:53 AM - 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:WATERMARK AT BEVERLY HILLS, THEFACILITY NUMBER:
197609311
ADMINISTRATOR:STEPHANIE WALTERSFACILITY TYPE:
740
ADDRESS:220 N CLARK DRIVETELEPHONE:
(310) 860-9234
CITY:BEVERLY HILLSSTATE: CAZIP CODE:
90211
CAPACITY:75CENSUS: 44DATE:
11/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:James "Jim" HowlandTIME COMPLETED:
04:35 PM
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On 11/16/2023 at 8:05 am Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection.

LPA met with Administrator, James “Jim” Howland. The Residential Care Facilities for the Elderly (RCFE) facility is licensed for 69 non-ambulatory residents of which 6 may be bedridden. Facility currently has 44 residents. The facility does not handle any of the residents’ money. Facility fire clearance is for a capacity of seventy-five (75) of which sixty-nine (69) residents are non-ambulatory and six (6) bedridden residents.



LPA and Jim toured the physical plant, checked food service. LPA reviewed Five (5) out of forty-three (43) staff members records. LPA España conducted interviews with Five (5) out of forty-three (44) residents and for medical status (MAR). The facility conducted a fire drill on 10/06/2023. The building has five (5) floors which includes the basement. The first floor includes the reception area, dining room, food service area, Administration offices, Salon, medication and records room. Medication Records Administration (MAR) observed at time of visit. Resident rooms were observed from the second floor to the 5th floor. LPA toured roof top and cooling tower. The parking lot is at the basement. Each floor has a common washer and dryer, a common restroom, and different activity room. Resident rooms are set up with beds, nightstands, closets, chests with drawers and chairs for each resident. Lighting in the rooms were adequate. Bathrooms were equipped with a shower with grab bars, and personal hygiene supplies. All the exit doors were clear of obstructions during the time of the visit. Common areas are appropriately furnished, and lighting was more than sufficient. Fire extinguishers are located in all the floors and the building is equipped with a sprinkler system. The first aid kits are complete with a thermometer, scissor, tweezers, bandage and a first aid manual. Facility evaluation report continued on LIC-809-C
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
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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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: WATERMARK AT BEVERLY HILLS, THE
FACILITY NUMBER: 197609311
VISIT DATE: 11/16/2023
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There is a patio area on the first floor. The patio area is complete with tables and chairs for residents use for comfort & enjoyment. Hot water temperature was tested in random resident rooms, common bathrooms and kitchen. Hot water temperatures measured between 105-120 degrees Fahrenheit (F) which are within the required range for residents’ comfort and safety. Rooms #516 hot water temperatures measured at 113 degrees Fahrenheit (F). Rooms #507 hot water temperatures measured at 111 degrees Fahrenheit (F). Rooms #416 hot water temperatures measured at 112 degrees Fahrenheit (F). Rooms #407 hot water temperatures measured at 111 degrees Fahrenheit (F). Rooms #316 hot water temperatures measured at 112 degrees Fahrenheit (F).

Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. LPA observe two days (2) of perishable and seven (7) non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly. LPA confirmed 115 carbon monoxide detector which were operational. Outside grounds were toured and no bodies of water were observed. There are no security bars or weapons on the premises.

No deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

One (1) Advisory Note: Technical Assistance was issued on today visit.

Licensing Program Analyst (LPA) David España and Administrator, James “Jim” Howland did not observe PUB 475 posted at the main entryway of the facility.

Exit interview conducted and a copy of the report and appeal rights were given at the time of the visit to Administrator, James “Jim” Howland.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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