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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320127
Report Date: 04/11/2023
Date Signed: 03/06/2024 02:46:19 PM


Document Has Been Signed on 03/06/2024 02:46 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/05/2024 02:16 PM

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

NARRATIVE
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This report serves as an amendment to condense the narrative, and remove narrative regarding concerns of window screens. It does not supersedes the report written by Licensing Program Analyst (LPA) David España who conducted a Case Management – Annual Continuation visit at Watermark at Westwood Village. On 04/11/2023 LPA España, met with Administrator Olga Kirskey, and explained that the purpose of today's visit is to complete the facility annual inspection conducted on 03/28/2023 and 03/29/2023. A review of the physical plant, facility records, staff records and resident's records were conducted during the said visits.

The facility has 188- living units, 225 bathrooms, 14 stories with underground parking. On the first floor, the facility has a full kitchen, dining area, lobby, conference room space, restrooms, reception area, 3 elevators and a sitting area with an enclosed fireplace. There is also a large outdoor patio with a fireplace and seating. On the second floor, there is a salon and fitness center, storage space and administrative office space. The third floor consist of residential space for individuals that need support with memory care. Which includes 18 apartments, a dining space with patio and some office space. Floors four to seven consist of residential space for assisted living. Floors eight to fourteen consist of units for independent living. The units are spacious and will easily accommodate furnishings. There are no open bodies of water on the premises. Building is equipped with a backup generator on-site. Facility has a full sprinkler system.

Deficiencies were observed during today’s visit and the visits conducted on 03/28/2023 and 03/29/2023: LPA and staff observed the following: exposed walls clearly visible with holes and no posted signs were observed of work being conducted in fire escape/stairway on ALL 14 floors, a machine blocking the emergency exit door in the Memory Care Unit stairwell, a watermark van non-operational were parked in front of the gate entrance to parking garage, knifes and cleaning solution chemicals in the kitchen area were observed, LPA did not observe CPR training for 3 staff, LPA did not observe educational verification for staff, LPA observed expired and out dated food, LPA did not observe a record of dosages of medications maintained by the facility. An exit interview was conducted, and plans of corrections were developed. A copy of this report and appeals rights were provided.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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 12


Document Has Been Signed on 04/11/2023 05:07 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: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(4)
Personal Accommodations and Services
(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA and staff when entering memory care on the 3rd floor noticed a machine blocking emergency exit door. LPA and staff did observe no lights in one fire escape/stairway, and water that obstructed the 14 floors of stairway. LPA observed exposed walls clearly visible with holes. No posted signs were observed of work being conducted in fire escape/stairway on ALL 14 floors. LPA detected 14 floors of exposed walls in the fire escape/stairway, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2023
Plan of Correction
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The Administrator will complete a Needs and Services Plan for the fire scape/Stairway and must be submitted to CCL by the POC due date of 5/11/23.
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: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 12


Document Has Been Signed on 03/06/2024 02:46 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/05/2024 02:20 PM

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: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operation
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA and staff observed a watermark van non-operational, and parked in front of the gate entrance to parking garage, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2023
Plan of Correction
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The Administrator will complete a Needs and Services Plan for the van which is non-operational and must be submitted to CCL by the POC due date of 5/11/23 (david.espana@dss.ca.gov).
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: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
LIC809 (FAS) - (06/04)
Page: 3 of 12


Document Has Been Signed on 04/11/2023 05:07 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: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. At 10:37AM LPA toured the facility with administrator S1 and S2 to include the kitchen area, LPA did observe knifes left on the counter box, and did find violations of Title 22 regulations regarding unlocked knifes which are meant to be kept in locked drawers. Additionally, LPA observed chemicals that were not stored or kept under lock drawers. LPA interviewed S2 about staff and chemicals and unlocked knifes, S2 stated he addressed the concern that very moment when observed and made corrections, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2023
Plan of Correction
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The Administrator will complete a Needs and Services Plan for the disinfectant, cleaning, solutions, and must be submitted to CCL by the POC due date of 5/11/23.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA observed no CPR training for staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2023
Plan of Correction
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The Administrator will complete a Needs and Services Plan for the CPR and must be submitted to CCL by the POC due date of 5/11/23 (david.espana@dss.ca.gov).
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: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 12


Document Has Been Signed on 04/11/2023 05:07 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: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(6)(A)
Personnel Records
(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA did not observe educational verification for a number of staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2023
Plan of Correction
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The Administrator will complete a Needs and Services Plan for the educational verification and must be submitted to CCL by the POC due date of 5/11/23.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA and staff did observed the facility perishable and nonperishable food supply. Licensee and staff stated they did not have any expired or out dated food. LPA did observe expired and/or out dated food, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2023
Plan of Correction
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The Administrator will complete a Needs and Services Plan for the expired out dated food and must be submitted to CCL by the POC due date of 5/11/23.
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: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 5 of 12


Document Has Been Signed on 04/11/2023 05:07 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: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA observed that follwoing R01 centrally stored medication log stated R01 should take a specific medication on a specific date, however, centrally stored medication did not correspond to specific dates observed on 03/28/23, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2023
Plan of Correction
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The Administrator will complete a Needs and Services Plan for the medication and must be submitted to CCL by the POC due date of 5/11/23 (david.espana@dss.ca.gov).
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 6 of 12


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: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127
VISIT DATE: 04/11/2023
NARRATIVE
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This report serves as an amendment to condense the narrative. It does not supersedes the report written by Licensing Program Analyst (LPA) David España conducted a Case Management – Annual Continuation visit at Watermark at Westwood Village.

This page is left blank intentionally.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 7 of 12
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: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127
VISIT DATE: 04/11/2023
NARRATIVE
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This report serves as an amendment to condense the narrative. It does not supersedes the report written by Licensing Program Analyst (LPA) David España conducted a Case Management – Annual Continuation visit at Watermark at Westwood Village.

This page is left blank intentionally.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 8 of 12
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: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127
VISIT DATE: 04/11/2023
NARRATIVE
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30
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32
This report serves as an amendment to condense the narrative. It does not supersedes the report written by Licensing Program Analyst (LPA) David España conducted a Case Management – Annual Continuation visit at Watermark at Westwood Village.

This page is left blank intentionally

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 11 of 12
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: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127
VISIT DATE: 04/11/2023
NARRATIVE
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This report serves as an amendment to condense the narrative. It does not supersedes the report written by Licensing Program Analyst (LPA) David España conducted a Case Management – Annual Continuation visit at Watermark at Westwood Village.

This page is left blank intentionally.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 12 of 12
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: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127
VISIT DATE: 04/11/2023
NARRATIVE
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This report serves as an amendment to condense the narrative. It does not supersedes the report written by Licensing Program Analyst (LPA) David España conducted a Case Management – Annual Continuation visit at Watermark at Westwood Village.

This page is left blank intentionally.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 9 of 12
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: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127
VISIT DATE: 04/11/2023
NARRATIVE
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This report serves as an amendment to condense the narrative. It does not supersedes the report written by Licensing Program Analyst (LPA) David España conducted a Case Management – Annual Continuation visit at Watermark at Westwood Village.

This page is left blank intentionally.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 10 of 12