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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802563
Report Date: 12/27/2021
Date Signed: 12/27/2021 04:38:34 PM

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:EL DESCANSO RETIREMENT HOMEFACILITY NUMBER:
197802563
ADMINISTRATOR:BOUSHERI, CLEMENCIAFACILITY TYPE:
740
ADDRESS:21020 E. CIENEGA AVENUETELEPHONE:
(626) 967-2868
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:15CENSUS: 15DATE:
12/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Clementia Bousherim, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Administrator, Clementia Bousheri who assisted with visit. The facility has a capacity of 15 residents. The facility is licensed to serve fifteen (15) Non-Ambulatory residents, ages 60 and above. The facility has an approved Hospice Waiver for six (6) residents on file. Currently, five (5) residents on hospice. Annual licensing fees are current. LPA discussed the purpose of today's visit with administrator.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.



The facility is a single story home located in a residential neighborhood, consisted of ten (10) resident bedrooms, six (6) bathrooms, reception area, Administrative office, living room, dining room, kitchen, TV room, sitting room, music/garden room, linen closet, laundry room, garage utilized as storage room and an indoor/outdoor activity area. Medications were centrally stored, locked and inaccessible to residents in care. Hallways were clean and free of obstructions. Common areas were well organized and free of hazards. Resident bedrooms had furniture, lighting fixtures and personal storage space as required. Mattress pads observed on all beds. The required amount of linen also observed. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature is in a range of 118.5 to 119.4 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. (-continued in LIC 809 C-)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EL DESCANSO RETIREMENT HOME
FACILITY NUMBER: 197802563
VISIT DATE: 12/27/2021
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All exit doors are equipped with auditory device alarms. Last Fire Drill was conducted on 12/10/2021. Administrator certificate is current with expiration date on 4/5/2023.

Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens and counter tops observed to be clean, plates, cups, glasses and utensils for the current census. A comfortable temperature of 70 degrees Fahrenheit maintained throughout the entire facility.

Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged and last service was on 4/8/21. First aid kits were fully stocked. All mandated documents and signages are posted in common areas.



Side and front yards are well maintained and free of debris. There is shaded outdoor area with ample seating. No bodies of water observed.

No deficiency was cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to facility Administrator,, whose signature on this form confirm receipt of these documents.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC809 (FAS) - (06/04)
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