198320378-5-16-2024-11-AS-DESA-D5BT8R-20240516143046

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320378
Report Date: 05/16/2024
Date Signed: 05/16/2024 02:32:08 PM

Document Has Been Signed on 05/16/2024 02:32 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:	SAVANT OF SANTA MONICA		FACILITY NUMBER:	198320378
ADMINISTRATOR:	ZENOU, ADAM		FACILITY TYPE:	740
ADDRESS:	1447 17TH STREET		TELEPHONE:	(310) 829-5904
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90404
CAPACITY:	174	CENSUS: 69	DATE:	05/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Administrator Ruby Cruz		TIME COMPLETED:	02:30 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	On 05/16/2024 Licensing Program Analyst (LPA), David España conducted an unannounced annual visit using the full care tools. LPA met with Administrator Ruby Cruz and the purpose of today's visit was explained. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections. The facility is licensed to serve (174) age range 60 and over adults. The fire clearance is approved for (150) non-ambulatory and (24) bedridden residents. LPA toured facility Kitchen, Dining Room, Living Room areas, (8) Bedrooms, (8) Bathrooms, Garage, and Patios with shaded areas. LPA observed sufficient storage areas for kitchen supplies, linens, medications (secured) and chemicals (secured). LPA observed the following during this visit: There is a locked centralized storage area for Resident medications. LPA reviewed 5 resident medications. LPA interviewed 7 residents in care. LPA interviewed 5 staff members. LPA observed the facility is clean, sanitary, and in good repair. Indoor and outdoor passageways, stairways, open areas, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68° degrees and 85° degrees. Open patios, and areas of potential hazard are well-lit. LIC809-C (cont)

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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: SAVANT OF SANTA MONICA	FACILITY NUMBER: 198320378
	VISIT DATE: 05/16/2024

NARRATIVE

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Carbon monoxide/Smoke detectors operate properly. 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. There is dresser and closet space for each client that includes at least two (2) drawers of dresser space per client. There is a chair and lamp for each client and at least one (1) nightstand per two (2) clients. There are plenty toilets and washbasins for clients, family, and personnel. There are plenty showers for clients, family, and personnel. Hot water temperature is between 105°-120° degrees Fahrenheit. Bathrooms are located inside client bedrooms and common areas. Public restroom calling system is operational. 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. Dining room is near kitchen. Refrigerator and freezer are clean and have the capacity to store at least two (2) days of perishable foods. There is storage for seven (7) day supply of non-perishable food. There are enough tableware, tables, dishes, and utensils. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. There is confidential storage for personnel records at the facility. There is storage for Resident confidential information and records at the facility. 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. LIC809-c (cont)

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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: SAVANT OF SANTA MONICA	FACILITY NUMBER: 198320378
	VISIT DATE: 05/16/2024

NARRATIVE

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There is an outdoor activity space with a shaded area and furnished for outdoor use. There are at least 3 common areas available to clients for visitors. There are activities scheduled during the current month. 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. LPA observed a sign-in/sanitation station at the facility entry. There is hand sanitizer located at the entrance of the facility. Facility has screening process for all visitors, sanitizer/soap, paper towels, and additional PPE supplies are stored inside the facility. LPA observed fire extinguishers were fully charged and last serviced on 05/09/2024. Fire alarm and sprinkler system were last serviced on 04/29/2024. Carbon Monoxide detector was operable.LPA inspected the First Aid and found it contained all the required items. The elevator was last serviced on 04/28/2023.

There was one technical assistance provided on today's visit.

Resident Records/Incident Reports - Technical Assistance: 87506(b)(11) - LPA with Administrator Ruby Cruz did not observe resident #1 (R1) complete file.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time. A exit interview was conducted with Ruby Cruz Administrator and a hard copy of a LIS 809s document was provided.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

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