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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204494
Report Date: 06/02/2023
Date Signed: 06/02/2023 01:35:50 PM


Document Has Been Signed on 06/02/2023 01:35 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:ATRIA PARK OF PACIFIC PALISADESFACILITY NUMBER:
198204494
ADMINISTRATOR:BRIAN LARIOSFACILITY TYPE:
740
ADDRESS:15441 W SUNSET BLVDTELEPHONE:
(310) 573-9545
CITY:PACIFIC PALISADESSTATE: CAZIP CODE:
90272
CAPACITY:60CENSUS: 38DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Remon Pagels, Executive DirectorTIME COMPLETED:
02:12 PM
NARRATIVE
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On 06/02/23, Licensing Program Analysts (LPAs) Antonine Richard and Mario Leon conducted an unannounced annual required, using the full CARE Inspection Tool. LPAs met with Executive Director Remon Pegels and explained the purpose of today’s visit. The facility is an RCFE licensed for sixty (60) non-ambulatory and also includes a hospice waiver for (10) ten. Currently, there are thirty eight (38) non-ambulatory residents residing in the facility, all are over the age of 59.

The facility is a three-story structure located in a residential neighborhood. It consists of the following: 40 (40) resident rooms with attached bathrooms, dining area, kitchen, garage, lounge, activity room and roof top, with shaded areas featuring table and chairs.

LPA and executive director toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage area for cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available, maintained properly. The water temperature was measured at 126.8 F in the industrial kitchen, which was not properly identified. Smoke detectors were observed in client rooms and are connected to the fire system. LPA reviewed Medication Administration Record (MAR) and observed it to be maintained in order and accurate.

See LIC809C
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ATRIA PARK OF PACIFIC PALISADES
FACILITY NUMBER: 198204494
VISIT DATE: 06/02/2023
NARRATIVE
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LPAs observed sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

Two deficiencies were cited during this inspection visit, see LIC809D.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Executive Director, Remon Pagels.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/02/2023 01:35 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: ATRIA PARK OF PACIFIC PALISADES
FACILITY NUMBER: 198204494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87218(a)(1)


This requirement is not met as evidenced by:
87218 Theft and Loss:
(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153.

(1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative.
Deficient Practice Statement
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Based on LPA's observation and record review, the licensee did not comply with the section cited above in not having safeguards of property and valuables present for one resident which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2023
Plan of Correction
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The licensee has agreed to aquire and provide the signed safeguards of property and valuables for the resident to LPA, via email, at Antonine.Richard@DSS.CA.GOV
OR
323.516.4092
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/02/2023 01:35 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: ATRIA PARK OF PACIFIC PALISADES
FACILITY NUMBER: 198204494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above in having the water temperature above 125 degree F in the industrial kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Corrected on-site by Administrator, Remon Pagels.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4