197609311-11-20-2024-11-AS-AINZ-DB82ZE-20241120165014

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609311
Report Date: 11/20/2024
Date Signed: 11/20/2024 04:50:23 PM

Document Has Been Signed on 11/20/2024 04:50 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	WATERMARK AT BEVERLY HILLS, THE		FACILITY NUMBER:	197609311
ADMINISTRATOR/ DIRECTOR:	JAMES HOWLAND		FACILITY TYPE:	740
ADDRESS:	220 N CLARK DRIVE		TELEPHONE:	(310) 860-9234
CITY:	BEVERLY HILLS	STATE: CA	ZIP CODE:	90211
CAPACITY: 75	TOTAL ENROLLED CHILDREN: 0	CENSUS: 49	DATE:	11/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:06 AM
MET WITH:	James Howland-Executive Director		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

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On 11/20/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with James Howland /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (75) elderly adults ages 60 and above non-ambulatory of which (6) can be bedridden. The facility has a pending hospice waiver by CCLD.

The facility is a commercial building located in a residential neighborhood, comprising five (5) floors, including a basement. The first floor includes a reception area, dining room, food service area, administrative offices, salon, medication room, and records room.

LPA Iniguez and the ED toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (5) bedrooms and (5) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 115.5°F to 117.2°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

Eva M Alvarez	TELEPHONE: (323) 629-7047
Alfonso Iniguez	TELEPHONE: 323-981-1755
	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WATERMARK AT BEVERLY HILLS, THE	FACILITY NUMBER: 197609311
	VISIT DATE: 11/20/2024

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During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 10/20/24.

A review of (5) residents' service files and (5) staff personnel files was maintained in order. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be email to LPA. Facility Annual Fess current.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-See D page for details.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to James Howland / Executive Director.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/20/2024 04:50 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WATERMARK AT BEVERLY HILLS, THE	FACILITY NUMBER: 197609311
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personnel Requirements - General

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. 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 above in facility staff taking more than 10 minutes to clear alarm from signal system which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/03/2024
	Plan of Correction
1 2 3 4	Licensee will ensure personnel is able to provide the services necessary to meet the residents needs. As plan of correction, executive directo will conduct an in-service trianing with direct care personnel regarding alarm sygnal system. Proof of training will be sent to LPA via email before POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Eva M Alvarez	TELEPHONE: (323) 629-7047
Alfonso Iniguez	TELEPHONE: 323-981-1755
	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

LIC809 (FAS) - (06/04)

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