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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609311
Report Date: 08/13/2022
Date Signed: 08/14/2022 08:10:56 AM


Document Has Been Signed on 08/14/2022 08:10 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
CCLD Regional Office, 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: 47DATE:
08/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Ali Foruz, Dining Services DirectorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met with Ali Foruz, Dining Services Director and the purpose of today’s visit was explained.

There are currently (47) residents in the facility. The facility is a 3 -story structure located in a residential neighborhood. It consists (59) bedrooms entire facility, 7 bathrooms: 1st floor & P1, Kitchen, Dining room, Offices, copy room, lobby, Well-ness center, private dining, library, lounge, beauty salon, multi purpose room, 4th flr: theater, linen closet, electrical room, and laundry room. Shaded back, front, and side patios, laundry room in P2 floor, P1: storage room.

LPA and Ali only toured the 1st floor & 4nd Flr rooms: 415,405, & 406, P1, P2, & outer perimeter only. Documents are posted as mandated in 1st and 4Th flr. Bedrooms in the 4th Flr contain the mandated furniture. All bathrooms in the 1st and 4nd flr. are clean and operational. No firearms are stored at facility and no bodies of water present. Hot water temperature is (120) degrees Fahrenheit, The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged, and temperature checked, sanitizer/soap in all the bathrooms and additional sanitation supplies are stored in storage area in the 5th Flr. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted or in folder, Fit testing completed for staff, and required postings throughout the facility. The resident’s temperatures are checked and logged (once a day). PPE's are enough for 30 days.

Due to time constraints LPA Soto could not complete annual, LPA will return at a later date. If any deficiencies noted they will be cited at the time of annual continuation. No, Technical Advisory (TA) issued.

A exit interview was conducted with Ali Foruz, Dining Services Director and a hard copy was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2022
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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