197802563-4-14-2023-28-AS-BTAO-CQVVYS-20230414165136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802563
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:53:09 PM

Document Has Been Signed on 04/14/2023 04:53 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: 15	DATE:	04/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:09 AM
MET WITH:	Clemencia Bousheri, administrator		TIME COMPLETED:	05:00 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 Administrator, Clemencia Bousheri, and Escarling Godoy, manager, who assisted with the visit. Facility capacity is fifteen (15) residents. The facility is licensed to serve fifteen (15) non-ambulatory residents who are ages 60 and above and approved for six (6) Hospice Waiver. Currently, six (6) residents on hospice. Annual licensing fees are current. LPA discussed the purpose of today's visit with administrator.

During the visit, LPA conducted staff and resident interviews, used inspection tool, toured the facility, reviewed food supply, reviewed medications, and reviewed staff and residents records.

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. All the rooms are furnished with appropriate furniture for residents’ comfort. The bathrooms are furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the residents. Hot water temperature was measured at 119.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Sufficient of linen supplies and personal hygiene supplies were observed.

All exit doors are equipped with auditory device alarms. Last fire drill was conducted on 3/5/2023.

(-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: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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 2

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: 04/14/2023

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
26
27
28
29
30
31
32

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. 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 was conducted. This report is discussed and provided to facility administrator, Clemencia Bousheri and Escarling Godoy, manager, whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2