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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205367
Report Date: 09/16/2023
Date Signed: 09/16/2023 03:15:07 PM


Document Has Been Signed on 09/16/2023 03:15 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:WESTCHESTER VILLAFACILITY NUMBER:
198205367
ADMINISTRATOR:EVANGELINE AGATEPFACILITY TYPE:
740
ADDRESS:220 W. MANCHESTER BLVD.TELEPHONE:
(310) 673-1093
CITY:INGLEWOODSTATE: CAZIP CODE:
90301
CAPACITY:174CENSUS: 85DATE:
09/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Evangeline Agatep-DirectorTIME COMPLETED:
03:14 PM
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On 9/16/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARES Inspection Tool. LPA met with Evangeline Agatep /Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (174) elderly adults ages 60 and above. Dementia special program- facility has delayed egress Facility has an approved hospice waiver for (3).

The facility is a two-story commercial building. the facility consisted of the following: The first floor Lobby/receptionist area, business office/ medication room/ record office, Administrator's office, 34 bedrooms and bathrooms, emergency supply room, beauty salon, storage rooms, 3 living rooms, dining rooms, kitchen, resident's private laundry room/commercial laundry room, activity room, recreation/activity director's office, men and women public restrooms, employee's lounges, men and women employee's restrooms, linen room, housekeeping supply room, patios, shaded area, indoor/outdoor activity area, and gated security parking lot. The second floor consisted of: 52 resident's bedrooms and bathrooms, men and women public restrooms, resident's private coin laundry room, TV room, library/living room, game room, storage rooms.

LPA Iniguez toured the physical plant with Administrator. There were no bodies of water or obstructions on the premises. A total of (8) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #127, #128, #112, #131, #237, #243, #213, #212; call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 109.5F° – 114.2F°. The rooms temperature ranged from 76F° – 78F°.

Evaluation Report continues on LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2023
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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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: WESTCHESTER VILLA
FACILITY NUMBER: 198205367
VISIT DATE: 09/16/2023
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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 09/11/20/23. Annual fire clearance performed on 9/11/20231. Working landline phones are available on-site. A review of (8) residents' service files (R1-R8) and (8) staff personnel files (S1-S8) and Medication Administration Records (MAR) were maintained in order.

LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted throughout the facility.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.



An exit interview was conducted, and a copy of the Facility Evaluation Report and Appeal Rights was provided to the Administrator/ Evangeline Agatep.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023
LIC809 (FAS) - (06/04)
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