198320184-9-29-2021-11-AS-PBUR-C7BPR5-20210929113209

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320184
Report Date: 09/21/2021
Date Signed: 09/29/2021 11:32:17 AM

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:	AVENIR MEMORY CARE WESTSIDE		FACILITY NUMBER:	198320184
ADMINISTRATOR:	DRINKHOUSE-QUINTA, MARISSA		FACILITY TYPE:	740
ADDRESS:	7501 OSAGE AVE		TELEPHONE:	(480) 451-8200
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90045
CAPACITY:	88	CENSUS: 0	DATE:	09/21/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Peggy Ulland, Marissa Drinkhouse- Quintana, Mat Whalen, and Cauleen Ritchie		TIME COMPLETED:	03:45 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) Pamela Bunker conducted an announced Pre-licensing visit. Upon arrival at the facility, LPA Bunker called Applicant Vice President of Programming and Health Care Development Peggy Ulland and conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA verified an approved Mitigation Plan Report. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA observed a sanitizing station at the entrance; visitors log with COVID-19 screening and temperature log, and records of daily COVID-19 screening and temperature checks. PPE supplies are readily available to staff, and an additional 60-day supply of PPE is stored in the storage room; sufficient paper, cleaning, and disinfecting supplies were observed. LPA reviewed the facility’s surveillance testing records. Applicant stated staff are fully vaccinated. All staff has completed the N95 fit testing requirement. An application was submitted to the State of California, Department of Social Service, Community Care Licensing Division (CCLD) dated June 07, 2021, for an initial application for Residential Care Facility for the Elderly (RCFE) ages 60 in above. The facility has a requested capacity of eighty-eight (88) non-ambulatory. The Fire Safety Inspection Request is granted and approved for 80 non-ambulatory and 8 bedridden residents. The applicant has been approved for a Dementia Care Program, and a Hospice Waiver. See continued LIC809-C on page #2

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AVENIR MEMORY CARE WESTSIDE	FACILITY NUMBER: 198320184
	VISIT DATE: 09/21/2021

NARRATIVE

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Continued LIC809-C page #2

Structure: The facility is a two-story commercial building located in a business and residential neighborhood which consisted of the following: There is a handwashing station, reception area, check-in station, lobby, cameras in common areas, there is 48 rooms, 88 beds, 48 bathrooms; 8 private rooms; 7 public restrooms, the first floor has 20 units, 36 beds, and the second floor has 28 units; 52 beds, living/family rooms, commercial kitchen; 2 bistro kitchens, dining rooms, staff lounge, mechanical room, maintenance room, nurses’ stations, conference room, offices, medication rooms, sitting areas, activity room, media lounge, physical therapy room, solarium room, salon, locked supply closets, laundry rooms, shaded areas, courtyards, indoor/outdoor activity areas, and a parking lot. The front and back yard landscape is in excellent condition at the time of the visit. Residents Bedrooms: Bedrooms #1-48 are designated as resident's bedrooms. The bedrooms have twin-size beds, chairs, nightstand, lamp, custom closet equipped with storage drawers, drawer space, sufficient lighting for each resident. Staff Bedroom: There is no bedroom designated for living in staff. Bathrooms: The bathrooms floors are clean, sanitary, and odorless, there are working toilets, washbasins, showers, grab bars, handicap shower chairs, non-skip mats in the shower, and closed lid trash cans. Linens & Hygiene Supplies: The required linen/supplies include: pillowcases, mattress paddings, fitted sheets, blankets, and comforters/bedspreads. An adequate supply of linens is kept in the housekeeping room. Hygiene supplies are stored in the medication rooms. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted and readily available for review in the lobby area and on each floor. The facility has landline telephones located throughout the facility. The food menu is posted on the wall in the hallway near the dining rooms.

See continued LIC809-C page #3

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4

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: AVENIR MEMORY CARE WESTSIDE	FACILITY NUMBER: 198320184
	VISIT DATE: 09/21/2021

NARRATIVE

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Continued LIC809-C page #3

Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected, and in good repair, knives, cutlery, and other sharp kitchen utensils will be stored in a locked drawer located in the kitchen. Smoke/Carbon Monoxide Detectors: There are hardwire smoke alarms and carbon monoxide detectors are located on each floor throughout the facility that is operational. There are (12) fully charged fire extinguishers located throughout the facility. Appliances: refrigerators, stoves/ovens, dishwashers, microwave, toaster, and washer/dryers are installed, and all are in working condition. There is central air and heating. There is a hot water heater located on the roof. Toxins: Cleaning supplies and toxins will be stored in a locked chemical supply closet located on the first and second floor in housekeeping and only accessible to staff. Water Temperature: The hot water was tested in the resident's suites, public restrooms, kitchen, and bistro, the temperature was tested at 116.9 -117.4 degrees Fahrenheit within the normal limits (105-120F degrees). Medication, First-Aid Kit & Manual: Centrally stored medications will be locked in the medication rooms on the first and second floors. There are sufficient bandages, tweezers, thermometers, scissors, and first aid kits with manuals. Staff & Residents Files: The staff and resident's records will be kept confidential in a locked cabinet in the business office. The facility will not handle any funds resident’s; family members will handle the cash resources of residents. Pools/Jacuzzi & Pets: No bodies of water on these premises. Residents are allowed pets. Fire Clearance: Fire clearance was approved on 08/19/2021. The facility yard is free of debris and hazard.

See continued LIC809-C page #4

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: AVENIR MEMORY CARE WESTSIDE	FACILITY NUMBER: 198320184
	VISIT DATE: 09/21/2021

NARRATIVE

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Continued LIC809-C page #4

Component III Orientation: Component III was completed with the Applicant during the Pre-Licensing visit. Information was provided about how to operate the facility within substantial compliance. When the applicant was asked if he understood Title 22 Regulations she responded in the affirmative.

Accordingly, LPA Bunker will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, she has been instructed to communicate with the CAU Analyst assigned to their application.

LPA Bunker provided Executive Director Marissa Drinkhouse--Quintana with a hard copy of the Facility Evaluation Report LIC809 and LIC809-Cs

An exit interview was conducted.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC809 (FAS) - (06/04)

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