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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609791
Report Date: 09/24/2023
Date Signed: 09/24/2023 02:35:25 PM


Document Has Been Signed on 09/24/2023 02:35 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
Lookup Error,
, CA



FACILITY NAME:ATWATER VILLAGE SOUTHFACILITY NUMBER:
197609791
ADMINISTRATOR:ESPIRITU, JOCELYNFACILITY TYPE:
740
ADDRESS:3454 PERLITA AVETELEPHONE:
(323) 665-6893
CITY:LOS ANGELESSTATE: CAZIP CODE:
90039
CAPACITY:6CENSUS: 6DATE:
09/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:ESPIRITU, JOCELYNTIME COMPLETED:
02:51 PM
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On 09/24/2023 at 12:40 pm, Licensing Program Analyst (LPA) David España conducted an unannounced required 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. LPA verified that the facility has an approved mitigation plan report.

LPA toured of the physical plant and noted the following: The facility has four (4) bedrooms and two (2) bathrooms currently occupying six (6) residents. One additional (1) bedroom is designated for staff use. The facility is fire cleared for age range 60 and over, 6 non-ambulatory, of which 1 may be bedridden, hospice waiver for 4. There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA were screened upon entry. All staff were observed to be wearing mask upon entrance and during visit. LPA observed signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the front and backyard. The facility has sufficient stock of PPE in the storage room.

LPA observed the living room is neat and clean along with the family room. The facility maintains a comfortable temperature at 70°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide installed in the kitchen. Fire extinguishers are located in the kitchen and dining area, observed to be full and last inspected on 11/23/2022. LPA observed the backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. LPA observed the garage is detached from the house and currently being used as frozen food, tools and other supplies storage. Laundry room is located adjacent to the kitchen.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2023
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: ATWATER VILLAGE SOUTH
FACILITY NUMBER: 197609791
VISIT DATE: 09/24/2023
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Laundry detergents, cleaning agents and other toxins are stored in a locked laundry area. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents.

LPA observed the Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. LPA observed the bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured a range of 105°F to 120°F. Towels and washcloths are not shared. There was enough clean linen available in stock cabinet. LPA observed medication cabinet to be locked and inaccessible to residents, located near the living room. There is a complete first aid kit located inside the medication cabinet.

No deficiencies cited. Exit interview conducted and a copy of this report was given at the time of visit, Jocelyn Espiritu, Administrator.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023
LIC809 (FAS) - (06/04)
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