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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609342
Report Date: 07/12/2022
Date Signed: 07/12/2022 03:44:22 PM

Document Has Been Signed on 07/12/2022 03:44 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LOS FELIZ GARDENSFACILITY NUMBER:
197609342
ADMINISTRATOR:SHAPIRO, NONNAFACILITY TYPE:
740
ADDRESS:205 E LOS FELIZ ROADTELEPHONE:
(818) 241-2273
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY: 199CENSUS: 125DATE:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Krystie Kim Business office Manager and Nonna Shapiro, AdministratorTIME COMPLETED:
03:51 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Maria Chengcunga, Med Tech and Business Office Manager Krystie Kim and explained the purpose of today's visit. LPA Also met briefly with Administrator Nonna Shapiro. Cettificate expires 06/18/23
Last fire drill was 05/24/22

This is an RCFE with a capacity of 199. This is a 3-story building which consists of 98 resident bedrooms, large living room, large dining room, activity room, TV room, wellness center, office and conference room.

The following were observed/inspected:
· COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, in all common rooms and hallways.
· Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Facility has (3) designated isolation are rooms on 1st floor and (3) on the 2nd floor available if a COVID-19 positive case should arise.
· 4 (Four) resident's medications were reviewed.
· PPE supplies observed. Hygiene supplies observed. Incontinence supplies observed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed (including paper goods, utensils ect).
· Residents were socially distanced according to local public health guidelines.

There are deficiencies noted. Please see (809D) for details.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Kyrstie Kim
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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 3
Document Has Been Signed on 07/12/2022 03:44 PM - It Cannot Be Edited


Created By: Alberto Lopez On 07/12/2022 at 02:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LOS FELIZ GARDENS
FACILITY NUMBER: 197609342

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. 13/13 rooms did not have paper towels in bathrooms and 2/13 bathooms did not have liquid soap which poses an immediate health safety or personal rights risk to persons in care.
POC Due Date: 07/12/2022
Plan of Correction
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Licensee purchased liquid soap and paper towels and placed them in each room during time of visit.

****No further action is required****
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1/4 counts. One resident medication list had medication that were discountinued and no discontinue order on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2022
Plan of Correction
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Licensee contacted resident's doctor and doctor provided discontinued order for resident's medication and updated file during visit.

****no further action is required****
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/12/2022 03:44 PM - It Cannot Be Edited


Created By: Alberto Lopez On 07/12/2022 at 02:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LOS FELIZ GARDENS
FACILITY NUMBER: 197609342

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. Room # 211 has hole in the wall behind the door stop which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2022
Plan of Correction
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Licensse will repair hole in the wall in room #211 and send photo as proof by POC date.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. 2 rooms (#140 and #145) did not have sliding screen doors which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2022
Plan of Correction
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Licensee will purchase sliding screen doors for room #140 and #145 and send photo as evidence by POC 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.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
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