198320402-7-19-2024-11-AS-AINZ-D7BTDH-20240719143823

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320402
Report Date: 07/19/2024
Date Signed: 07/19/2024 02:38:40 PM

Document Has Been Signed on 07/19/2024 02:38 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:	WESTMONT OF CULVER CITY		FACILITY NUMBER:	198320402
ADMINISTRATOR:	FLAHERTY, TRACY		FACILITY TYPE:	740
ADDRESS:	11141 WASHINGTON BLVD		TELEPHONE:	(310) 736-4118
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90232
CAPACITY:	160	CENSUS:	DATE:	07/19/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Tracey Flaherty/Executive Director		TIME COMPLETED:	02:38 PM

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On 7/19/24 Licensing Program Analysts (LPA’s) Deborah Lee, Yolanda Rosser and Alfonso Iniguez conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with authorized administrator: Tracy Flaherty.

The licensee has applied for a license to serve (160) elderly residents age range 60 and over. The fire clearance is approved for (160) non-ambulatory only. Approved hospice waiver for (20).

A tour of the entire facility was conducted: 1^st, 2^nd, 3^rd, 4^th, and 5^th floors, kitchen, common areas, outside of facility, medication rooms, records room, bathrooms, activity room, fitness center, and cinema room.

The following was observed during this visit:

MEDICATIONS

There are locked storage areas for Resident medications.

PHYSICAL PLANT

Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 73°F. degrees. Areas of potential hazard are well-lit. Smoke alarms operate properly. Carbon monoxide detectors operate properly.

Report continues LIC 809C.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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: WESTMONT OF CULVER CITY	FACILITY NUMBER: 198320402
	VISIT DATE: 07/19/2024

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BEDROOMS

There is a space for client’s own furniture that will accommodate a bed, a chair, a nightstand, a lamp, reading lights and a chest of drawers.

BATHROOMS

There is at least (137) toilet and washbasin per six (6) clients, family, and personnel. There is at least (137) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is between 105F°. and 120F°. Bathrooms are located inside clients’ bedrooms. There are nightlights in the hallways outside non-private bathrooms.

SUPPLIES

There are client personal hygiene supplies to include 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° Fahrenheit. Refrigerator is a maximum of 45° Fahrenheit. A seven (7) day supply of non-perishable food is present. There are enough tableware, tables, dishes, and utensils. There is enough 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.

Report continues LIC 809C.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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: WESTMONT OF CULVER CITY	FACILITY NUMBER: 198320402
	VISIT DATE: 07/19/2024

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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.

ACTIVITIES

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.

DELAY EGGRESS and SECURE PERIMETER

Delay egresses are located on the 1^st floor memory care entry.

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 commercial 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. Copy of liability insurance was email to LPA during this visit.

Report continues LIC 809C.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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: WESTMONT OF CULVER CITY	FACILITY NUMBER: 198320402
	VISIT DATE: 07/19/2024

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During this pre-licensing inspection, LPAs did not find corrections were needed. LPA Iniguez conducted the Component III Orientation with the administrator and copy of this report was provided. A copy of the facility evaluation report will be available 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 their assigned CAU Analyst.

Exit interview conducted with Tracey Flaherty/Administrator

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

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