197802563-4-8-2025-28-AS-MGFS-DFJQJQ-20250408121308

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802563
Report Date: 04/08/2025
Date Signed: 04/08/2025 12:13:27 PM

Document Has Been Signed on 04/08/2025 12:13 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	EL DESCANSO RETIREMENT HOME		FACILITY NUMBER:	197802563
ADMINISTRATOR/ DIRECTOR:	BOUSHERI, CLEMENCIA		FACILITY TYPE:	740
ADDRESS:	21020 E. CIENEGA AVENUE		TELEPHONE:	(626) 967-2868
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY: 15	TOTAL ENROLLED CHILDREN: 0	CENSUS: 12	DATE:	04/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:06 AM
MET WITH:	Escarling Godoy - Manager		TIME VISIT/ INSPECTION COMPLETED:	12:30 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) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Escarling Godoy Manager and explained the reason for the visit. The facility is licensed to serve fifteen (15) non-ambulatory residents, ages 60 and above, and had six (6) Hospice Waiver approved. Facility is a single home located in a residential neighborhood. It consist of a lobby area, office, a kitchen, a family room, a dining room, 10 resident rooms, 5 resident bathrooms, 1 staff bathroom, a garage, a laundry area, a front porch, a back yard. LPA reviewed the following CARE inspection tool domains during this visit: Infection Control: Infection control plan was reviewed which meets current regulations. Hand sanitizer and proper sanitation was observed during the visit. There is a responsible person and emergency training was provided to staff. Personal protective equipment was observed. Operational Requirements: Facility maintains a plan of operation. Facility has a current liability insurance. Facility is operating within the license. Physical Plant/Environmental Safety: LPA conducted a tour of the facility with Escarling Godoy and observed the following: Facility was observed in good repair indoors and outdoors. All common areas are clean, and providing sufficient sitting area, and lighting. Kitchen area is clean, sharps were observed locked in a box. Medications were observed locked in the office. Cleaning supplies were observed inaccessible to residents in the garage. Laundry area was observed in good repair. LPA observed 5 random resident rooms, each in good repair, with all bedding supplies, and sufficient lighting. Five bathrooms were observed all in good repair, with grab bars, and non-slip shower floors. (CONTINUED ON LIC 809C)

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EL DESCANSO RETIREMENT HOME	FACILITY NUMBER: 197802563
	VISIT DATE: 04/08/2025

NARRATIVE

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Water temperature was tested in the resident bathrooms between 115.5 - 127.5 degrees F., which is not within 105-120 degrees F. Carbon Monoxide/Smoke detectors were tested and are in working condition. Fire extinguishers were observed and last checked on 9/25/24. The backyard has a cover shaded area.
Staffing: Administrator Clemencia Bousheri arrived at the facility shortly after. Staff have current CPR/First Aid training on file. Night staff have been provided emergency training. Sufficient staff were observed.
Personnel Records/Staff Training: Administrator certificate was observed for Clemencia Bousheri #6004291740 exp. date: 4/5/25. Renewal documents have been submitted to the department. All staff records were available for review. LPA reviewed a total of 5 staff files which included medical assessment, TB clearance, background clearance, and initial and yearly training.
Resident Rights/Information: Personal Rights, Let Us No poster (PUB 345), and Local Ombudsman posters were observed throughout the home.
Planned Activities: Activity materials were observed. Outdoor area has a seating area and activity supplies to promote outdoor activities.
Food Service: Sufficient food supplies were observed of perishables for at least 2 days and non-perishables for at least 7 days. There are residents with special diets, staff prepare meals accordingly. No pest was observed.
Incidental Medical and Dental: There is an area designated to centrally stored medication in the office. Medications are label and in their original containers. LPA reviewed medication for 5 residents.
Resident Records/Incident Reports: Residents records were available for review. LPA reviewed a total of 5 resident files which contained medical assessment, TB clearance, admission agreement, an appraisal, a needs and care plan.
Disaster Preparedness: Emergency Disaster plan (LIC 610E 10/03) was last reviewed on 1/1/25 and an emergency disaster plan was reviewed. Last Emergency drill was conducted on 3/125 and they conduct monthly emergency drills.
Residents with Special Health Needs: There are no residents with restricted health conditions under care. Facility is following dementia regulations. Medical assessments for residents with dementia were observed within the last 12 months. Auditory devices were observed in each exit door. Facility currently has three residents on hospice and keeps hospice plan on file. LPA interviewed 3 residents and 3 staff.

Deficiency was noted per Title 22 Regulations.
Exit interview was conducted with Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/08/2025 12:13 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
GREATER LA AC/SC, 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: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in water temperature tested in bathrooms #2-5 between 115.5 - 127.5 which is not within the required 105-120 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/09/2025
	Plan of Correction
1 2 3 4	Administrator will certify in writing that will ensure that water temperature is between 105-120 degrees F. and will submit a water temperature log tracking dailiy water temperature for 7 days submit by 4/16/25.

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.

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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