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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320127
Report Date: 03/10/2025
Date Signed: 03/10/2025 07:35:55 PM

Document Has Been Signed on 03/10/2025 07:35 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:WATERMARK AT WESTWOOD VILLAGE, THEFACILITY NUMBER:
198320127
ADMINISTRATOR/
DIRECTOR:		STEPHANIE KOFFMANFACILITY TYPE:
740
ADDRESS:947 TIVERTON AVENUETELEPHONE:
(310) 208-4590
CITY:LOS ANGELESSTATE: CAZIP CODE:
90024
CAPACITY: 237CENSUS: 136DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:49 AM
MET WITH:Stephanie Koffman/Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 3/10/2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Stephanie Koffman /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (237) elderly adults ages 60 and above, of which (237) can be non-ambulatory and (25) bedridden on the 3rd floor. Approved for delayed egress. The facility has an approved hospice waiver for (25). Currently the facility has (136) residents.

The facility features approximately (188) living units and around (225) bathrooms, spread across (14) stories with underground parking. The building is beige and predominantly made of glass. On the first floor, there is a full catering kitchen, a dining area, a lobby, conference room space, restrooms, a reception area, and (3) elevators. Additionally, a sitting area with an enclosed fireplace and a large outdoor patio with a fireplace and seating are also available. The 2nd floor includes a salon, a fitness center, storage space, and administrative office space. The 3rd floor is dedicated to residential accommodations for individuals requiring memory care support, with 18 apartments, a dining space that includes a patio, and some office space. Floors 4th to 7th are designated for assisted living residences, while floors eight to fourteen house units for independent living.

LPA Iniguez and the Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (7) bedrooms and (7) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 113.5°F to 117.2°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127
VISIT DATE: 03/10/2025
NARRATIVE
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During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 9/3/24.

A review of (5) residents' service files and (10) staff personnel files. LPA reviewed (5) Medication Administration Records (MARs) and found no discrepancies.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-9 facility employees not associated on guardian. (Civil Penalty Rendered).

-3 Facility employees with no TB Test/Health Screening on file.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Stephanie Koffman / Executive Director.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/10/2025 07:35 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 03/10/2025 at 02:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

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 in not having 9 facility staff associated including the executive director which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Licensee will adhere to Title 22 regualtions at all times. As plan of correction, licensee will associate the 9 employees and send proof of association to LPA via email before POC due date.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/10/2025 07:35 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 03/10/2025 at 02:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WATERMARK AT WESTWOOD VILLAGE, THE
FACILITY NUMBER: 198320127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 in not having a TB test on file for (3) facility employees which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2025
Plan of Correction
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Licensee will adhere to Title 22 regulations at all times. As part of plan of correction, licensee will sent proof of employee's TB test vial email before POC due date.

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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
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