198320319-5-22-2023-11-AS-DESA-CS3PNW-20230522112838

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320319
Report Date: 05/22/2023
Date Signed: 05/22/2023 11:29:01 AM

Document Has Been Signed on 05/22/2023 11:29 AM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	BEVERLY HILLS HOME		FACILITY NUMBER:	198320319
ADMINISTRATOR:	GHODSIAN, SHAROUZ		FACILITY TYPE:	772
ADDRESS:	450 SOUTH LA PEER DRIVE		TELEPHONE:	(310) 709-7355
CITY:	BEVERLY HILLS	STATE: CA	ZIP CODE:	90211
CAPACITY: 6		CENSUS: 0	DATE:	05/22/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:06 AM
MET WITH:	Administrator Dr. Sharouz Ghodsian		TIME COMPLETED:	11:47 AM

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On 05/22/2023 Licensing Program Analyst (LPA) David España conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA was greeted at the front entrance by Administrator Dr. Sharouz Ghodsian and was granted access in the facility.

Dr. Sharouz Ghodsian submitted an application to Community Care Licensing Division (CCLD), for initial license for a Social Rehabilitation Facility to serve adults age range 18 through 59.

The requested capacity is for 6 clients of which are ambulatory clients. The facility is a 3-bedroom, 3 bathrooms, 1 story house. LPA España conducted a review of the Physical Plant, Bedrooms, Bathrooms, Supplies, Food Service, Medications, Records, Administration, Activities, Pre-Licensing Checklist and Component III Orientation.

MEDICATIONS: There is a locked centralized storage area for client medications.

PHYSICAL PLANT: Facility is clean, sanitary, and in good repair. Protective devices are in place to include nonslip material on rugs. Indoor and outdoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. There is no pools and bodies of water that need fencing of at least five (5) feet high with self-closing, self-latching gates, or locked covers that can support the weight of an adult.

There is no locked storage area for firearms, poisons, and dangerous weapons. There is no separate locked storage area for ammunition. All window screens are clean and in good repair. Facility temperature is between 68 degrees and 85 degrees. Fireplaces and open-faced heaters are inaccessible to clients. Stairways, inclines, ramps, open porches, and areas of potential hazard are well-lit and equipped with sturdy hand railings. Fire Alarms and Smoke alarms operate properly. Carbon monoxide detectors operate properly.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS HOME	FACILITY NUMBER: 198320319
	VISIT DATE: 05/22/2023

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BEDROOMS: Halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings are not being used as client bedrooms. Client bedrooms are large enough to allow for easy passage and to accommodate furniture and assistive devices such as wheelchairs, walkers, or oxygen equipment. No client bedroom is a passageway to another room, bath, or toilet. There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair. Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client. There is a chair and lamp for each client and at least one (1) nightstand per two (2) clients.

BATHROOMS: There is at least one (1) toilet and washbasin per six (6) clients, family, and personnel. There is at least one (1) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is between 105-120 degrees Fahrenheit. Bathroom is located near client bedrooms. There are nightlights in the hallways outside non-private bathrooms.

SUPPLIES: There are client personal hygiene supplies to include feminine napkins, soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths.

FOOD SERVICE: Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0 degrees Fahrenheit. Refrigerator is a maximum of 45 degrees Fahrenheit. A seven (7) day supply of non-perishable food is present. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

RECORDS: There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility.

ADMINISTRATION: The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS HOME	FACILITY NUMBER: 198320319
	VISIT DATE: 05/22/2023

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ACTIVITIES: For facilities of seven (7) or more capacity, an activities calendar is posted. There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. There are activity supplies to include newspapers, magazines, and a variety of reading material.

MISCELLANEOUS: There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. Vehicles used to transport clients are in safe operating condition.

PRE-LICENSING CHECKLIST: Completed by licensee and reviewed by LPA.

COMPONENT III: Provided via video conference, information was provided about how to operate the facility within substantial compliance. During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA by 06/02/2023. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction. 1. Disaster Plan/Disaster Preparedness (At least two appropriate shelter locations are required for evacuation purposes per California Code of Regulations, Title 22)

An exit interview was conducted, and a hard copy of this report has been provided to the applicant, Administrator Dr. Sharouz Ghodsian.

Accordingly, LPA 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, they have been instructed to communicate with the CAU Analyst, Nicole Madison Rouse, Associate Governmental Program Analyst assigned to the applicant, Administrator Dr. Sharouz Ghodsian.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

LIC809 (FAS) - (06/04)

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