198320184-10-31-2023-11-AS-RCLD-CX627W-20231031170924

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320184
Report Date: 10/31/2023
Date Signed: 10/31/2023 05:09:55 PM

Document Has Been Signed on 10/31/2023 05:09 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	AVENIR MEMORY CARE WESTSIDE		FACILITY NUMBER:	198320184
ADMINISTRATOR:	JODI KANOWITZ		FACILITY TYPE:	740
ADDRESS:	7501 OSAGE AVE		TELEPHONE:	(424) 282-0040
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90045
CAPACITY:	88	CENSUS: 46	DATE:	10/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:22 AM
MET WITH:	Jodi Kanowitz		TIME COMPLETED:	05:10 PM

NARRATIVE

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On 10/31/2023 at 8:22 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with Concierge. Forty-six (46) residents were present during this inspection.

Structure: The facility is a two-story commercial building located in a business and residential neighborhood which consisted of the following: There is a hand washing station, reception area, check-in station, lobby, cameras in common areas, 48 resident rooms to accommodate 88 residents, 7 public restrooms, 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, locked laundry rooms, shaded areas, courtyards, indoor/outdoor activity areas, and a parking lot.

Physical Plant LPA and Marketing Director toured the facility inside and out. The front and back were landscape and in excellent condition at the time of the visit. All patios have table, chairs and umbrellas. Two of the patios are used for outdoor activities and have games set up. All walkways are clean and clear of hazards, obstructions and debris. LPA did not observe any bodies of water. There are no security bars or weapons on the premises.

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, and sufficient lighting for each resident. .

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AVENIR MEMORY CARE WESTSIDE	FACILITY NUMBER: 198320184
	VISIT DATE: 10/31/2023

NARRATIVE

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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. Los Angeles Fire department completed its elevator test on 10/31/23, Stored Electrical Energy System, Fire Alarm, Automatic Closing Fire Assemblies and Fire Sprinkler System Initial Tests on 09/30/23.

5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates, training hours, and had required criminal record clearances. 3 staff were interviewed.

5 resident records were reviewed and 5 out of 5 client records had Admission Agreements. 3 medication records were reviewed and 3 residents were interviewed.

Infection Control Plan was reviewed and discussed with the Administrator Jodi Kanowitz, Plan of Operation (including dementia and bedridden plan) was reviewed, and emergency disaster plan was reviewed.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and left with Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/31/2023 05:09 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AVENIR MEMORY CARE WESTSIDE	FACILITY NUMBER: 198320184
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87618(b)(3)

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, facility tour, and record review, the licensee did not comply with the section 87616(b)(3)(A), 87616(b)(3)(B), 87616(b)(3)(E). LPA did not observe a written notice to the local fire department, no smoking signs in the appropriate areas, nor secured oxygen tank, which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/15/2023
	Plan of Correction
1 2 3 4	The administrator will present proof of correction via email to regina.cloyd@dss.ca.gov before the POC due.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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 Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

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