<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320127
Report Date: 03/28/2023
Date Signed: 05/16/2023 04:49:56 PM


Document Has Been Signed on 05/16/2023 04:49 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/14/2023 08:37 AM

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
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
This report serves as an amendment to clarify the facilities census of 76. It does not supersedes the report written on 03/28/23.

On 03/28/2023 at 08:45 AM, Licensing Program Analyst (LPA) David Espana conducted an unannounced comprehensive annual inspection visit at the Watermark at Westwood Village.



LPA Espana was provided access and entry to the facility by Administrator Shakeb Rafat and Jim Howland, Dining Services Director. Administrator Shakeb Rafat was asked questions regarding the full care tools (2) sections. Staff took LPA temperature prior to entrance into the facility.

Currently, the facility is licensed for: age range 60 and over. 237 non-ambulatory, of which 25 may be bedridden. 3rd floor and below approved for bedridden. 3rd floor only approved for delayed egress. hospice waiver for 25.

As part of the inspection, LPA reviewed:four (4) resident medication records, one of five (1 of 5) residents’ interviews, and one of five (1of 5) staff interviews.

No deficiencies were cited during today's visit 03/28/2023. Due to time constraints on 03/28/2023 subsequent visit is required.

The exit interview report was provided to Lilit Mnatsakanyan, Administrator with signatures and a date, who speaks on behalf of the facility's Administrator.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
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 2