197802563-4-21-2022-28-AS-BTAO-CDPVB8-20220421161706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802563
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:17:18 PM

Document Has Been Signed on 04/21/2022 04:17 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:	EL DESCANSO RETIREMENT HOME		FACILITY NUMBER:	197802563
ADMINISTRATOR:	BOUSHERI, CLEMENCIA		FACILITY TYPE:	740
ADDRESS:	21020 E. CIENEGA AVENUE		TELEPHONE:	(626) 967-2868
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	15	CENSUS: 13	DATE:	04/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Clementia Bousherim, Administrator Godoyvega Escarling, staff		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Godoyvega Escarling, staff, who assisted with the visit. Administrator, Clementia Bousheri joined the visit in 30 minutes later. The facility has a census of thirteen (13) 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, four (4) 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 116.5 to 118.4 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 Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

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: 04/21/2022

NARRATIVE

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All exit doors are equipped with auditory device alarms. Last fire drill was conducted on 04/01/2022. Administrator certificate is current with expiration date on 04/05/2023.

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 are sufficient for the current census. A comfortable temperature of 73 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 04/14/22. 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.

Deficiency was cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to facility staff Administrator, Clemencia Bousheri, whose signature on this form confirm receipt of these documents. A copy of the Appeal right is provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/21/2022 04:17 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EL DESCANSO RETIREMENT HOME	FACILITY NUMBER: 197802563
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/21/2022

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Stove top burners in the kitchen are not working properly. Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2022
	Plan of Correction
1 2 3 4	Administrator stated she planned and agreed to replace the old stove with a new stove. Administrator will ensure all stove tops will be working. Plan of Correction (POC) must be corrected by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC809 (FAS) - (06/04)

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