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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802563
Report Date: 04/23/2024
Date Signed: 04/23/2024 03:45:29 PM


Document Has Been Signed on 04/23/2024 03:45 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 HOMEFACILITY NUMBER:
197802563
ADMINISTRATOR:BOUSHERI, CLEMENCIAFACILITY TYPE:
740
ADDRESS:21020 E. CIENEGA AVENUETELEPHONE:
(626) 967-2868
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:15CENSUS: 14DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Staff#1, staff in chargeTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with staff#1, who assisted with the visit. Facility capacity is fifteen (15) residents. The facility is licensed to serve fifteen (15) non-ambulatory residents, ages 60 and above, and had six (6) Hospice Waiver approved. Annual licensing fees are current. Administrator certificate is current with expiration date on 4/5/25. LPA discussed the purpose of today's visit with staff#1.

During the visit, the inspection tool was used, staff and resident interviews were conducted, food supply/medications/ staff and residents records were reviewed,and physical plant was conducted.



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. Hot water temperature was measured at 114.0 degrees Fahrenheit which was within Title 22 Regulation guidelines. Sufficient of linen supplies and personal hygiene supplies were observed. Auditory device alarms were operational. Last fire drill was conducted on 4/4/24. Sufficient supply of perishable and non-perishable foods was observed. Smoke detectors and carbon monoxide detectors were tested and operable. Side and front yards are well maintained and free of debris. A shaded outdoor area with ample seating was observed. No bodies of water observed.

No deficiency was cited per California Code of Regulations, Title 22. An exit was conducted. This report was discussed and provided to staff#1.

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
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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