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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609311
Report Date: 09/10/2022
Date Signed: 09/11/2022 08:06:51 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/11/2022 08:06 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:
09/10/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ali Foruz, Dining Service DirectorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual continuation case management required 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, 65 bathrooms including common areas. The 2nd floor contains a gym, linen chute, electrical room, resident laundry room. The 3rd floor contains linen chute, guest suite, electrical room, and resident laundry room.

LPA and Ali only toured the entire 2nd floor & 3rd Floors. Which included rooms: 201, 204, 301, 304, 310. Documents are posted as mandated in 2nd and 3rd floors. Bedrooms in the 2nd & 3rd Floors contain the mandated furniture. All bathrooms in the 2nd and 3rd floors are clean and operational. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance. Medications are stored, locked and inaccessible to residents. (6) Resident file along with medications are current. Staff files were not available for LPA review. Ample supply of perishable and non-perishable foods. linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (6) fire extinguisher are fully charged. wThe facility is in good repair.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Ali Foruz, Dining Service Director
Due to technical difficulties (printer not working) Report and Appeal Rights will be provided by email.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2022
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 2


Document Has Been Signed on 09/11/2022 08:06 AM - 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: WATERMARK AT BEVERLY HILLS, THE
FACILITY NUMBER: 197609311

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2022
Section Cited

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87412(f)All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...This was not met as evidence by: Based on staff reords were not available for LPA's review. Which poses a potential health and safety risk for all persons in care.

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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2022
LIC809 (FAS) - (06/04)
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