198204999-3-4-2022-11-AS-UCOL-CC7W3W-20220304155637

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204999
Report Date: 03/04/2022
Date Signed: 03/04/2022 03:57:23 PM

Document Has Been Signed on 03/04/2022 03:57 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	AMERICARE ASSISTED LIVING OF WESTCHESTER		FACILITY NUMBER:	198204999
ADMINISTRATOR:	PATRICK BAUTISTA		FACILITY TYPE:	740
ADDRESS:	8501 RAMSGATE AVENUE		TELEPHONE:	(310) 641-5808
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90045
CAPACITY:	6	CENSUS: 6	DATE:	03/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:19 PM
MET WITH:	Patrick Bautista and Leia Joaquin		TIME COMPLETED:	04:15 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) Ulysses Coronel and LPA Antonia Alvizar conducted an unannounced Annual required visit with a primary focus on infection control measures. LPAs were met by Leia Joaquin, licensee and the purpose of today’s visit was explained. The facility is licensed to serve up to 6 residents ages 60 and over of which up to four (4) may be non-ambulatory and up to two (2) may be bedridden in rooms #4 and #5. Hospice approval for up to two (2) residents. There are currently 6 residents in placement. The facility has two stories and is located in a residential area, it consists of: 6 resident bedrooms, 1 staff bedroom, 3 resident bathrooms, 1 staff bathroom, living room, dining area, and kitchen. LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. 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. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected LPA’s observed nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises which is stored properly. Fire extinguishers were charged, smoke detectors and Carbon Monoxide detectors were operable. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations located in common areas and restrooms. LPA observed staff were wearing face coverings, and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

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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Document Has Been Signed on 03/04/2022 03:57 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMERICARE ASSISTED LIVING OF WESTCHESTER	FACILITY NUMBER: 198204999
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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 the hot water temperature in bathroom number 1 tested at 130.6 F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2022
	Plan of Correction
1 2 3 4	The licensee had the the water temperature down and will create a plan to ensure that Hot water temperature controls are 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). Proof of correction will be submitted 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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/04/2022 03:57 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMERICARE ASSISTED LIVING OF WESTCHESTER	FACILITY NUMBER: 198204999
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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 as the exit in bedroom number 6 is obstructed by the residents bed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/18/2022
	Plan of Correction
1 2 3 4	During todays visit the licensee had the bed moved aside and agreed to create a plan to ensure that all outdoor and indoor passageways and stairways are kept free of obstruction. Proof of correction will be submitted by the POC due date. LPA may conduct an unannounced visit to verify correction.

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

LIC809 (FAS) - (06/04)

Page: 3 of 9

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMERICARE ASSISTED LIVING OF WESTCHESTER	FACILITY NUMBER: 198204999
	VISIT DATE: 03/04/2022

NARRATIVE

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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit LPAs observed that the exit in bedroom #6 is obstructed by the resident’s bed. During today’s visit the hot water temperature measured at 130.6 Fahrenheit, Title 22, Division 6 and Chapter 8 is being cited on attached LIC809D form.

Plans of corrections were developed and exit interview held. A copy of the report and appeals rights was provided to Leia Joaquin, licensee.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

LIC809 (FAS) - (06/04)

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