198320491-9-12-2024-11-AS-HENZ-D92VPT-20240912163715

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320491
Report Date: 09/12/2024
Date Signed: 09/12/2024 04:39:27 PM

Document Has Been Signed on 09/12/2024 04:39 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:	OCEAN PEARL SENIOR LIVING		FACILITY NUMBER:	198320491
ADMINISTRATOR/ DIRECTOR:	NAHUM, AVIEL		FACILITY TYPE:	740
ADDRESS:	2590 S WESTGATE AVE.		TELEPHONE:	(424) 392-3482
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90064
CAPACITY: 6		CENSUS: 0	DATE:	09/12/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:08 PM
MET WITH:	Licensee Aviel Nahum		TIME VISIT/ INSPECTION COMPLETED:	05:00 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 09/12/24, Licensing Program Analyst (LPA) Hollie Enriquez conducted announced Pre-Licensing Inspection Visit to this facility. LPA was met by applicant Aviel Nahum and the purpose of the visit explained. An application was submitted to CCLD on 07/21/24 for a Residential Facility for the Elderly, ages 60 years and above. The applicant requested a capacity of six (6) individuals, of which three (3) may be non-ambulatory and three (3) may be bedridden. The Fire Clearance granted on 07/12/2024 noted the following special conditions of approval: “Only 1 bedridden client allowed due to there being no sprinklers in the home. Bedrooms 2,3, and 4 are approved for non-ambulatory and bedridden clients. Bedroom 1 approved for ambulatory client only.” Structure: The home is a single-story home in a residential neighborhood. The home consists of four (4) bedrooms, one (1) resident bathroom, (1) staff bathroom, (1) car garage used to for storage. The home includes a living, dining, kitchen, and laundry area. The living room has a decorative only fireplace that has a protective metal grill as a front barrier. The living area included cushioned chairs and tables. The kitchen has a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. Continued on 809C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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: OCEAN PEARL SENIOR LIVING	FACILITY NUMBER: 198320491
	VISIT DATE: 09/12/2024

NARRATIVE

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Smoke Detectors:
Smoke and carbon monoxide combination detectors are located throughout the interior space. The combination detectors are hardwired in all bedrooms, hallways and common living areas.

Toxins:
All toxins are locked and stored under the kitchen sink cabinet.

Appliances:

Oven, microwave, washer, and dryer are working. The kitchen counters also had small appliances which includes toaster, air fryer, built-in microwave oven, and coffee maker. There is one (1) refrigerator in the home. The refrigerator measured a temperature of at least 40 degrees Fahrenheit for appropriate food storage. The gas stove range was tested and would not ignite at the time of the visit.

Water Temperature:
The water temperature was measured in the client bathroom at 112.6 degrees F.

Medications, First-Aid Kit & Book:
A first aid kit is stored in the medication cabinet inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The resident's medications will be stored in a cabinet locked and inaccessible to residents.
Continued on 809C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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: OCEAN PEARL SENIOR LIVING	FACILITY NUMBER: 198320491
	VISIT DATE: 09/12/2024

NARRATIVE

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Bedrooms Residents:
The facility has four (4) bedrooms for residents. Bedroom 1 is single occupancy designated ambulatory only. Bedroom 2 is single occupancy and may be non-ambulatory or bedridden and bedrooms 3 and 4 are double occupancy designated non-ambulatory or bedridden. All rooms include a twin-size bed, one (1) chair, one (1) nightstand, and one (1) table lamp. All bedrooms are equipped with a ceiling light. All rooms had a dresser, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage.

Bathrooms:
The home has one (1) resident bathroom. Bathrooms are accessible from all rooms. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats. There is one (1) staff restroom with toilet and sink only.

Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the hall closet inside the bedrooms.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There is one (1) fire extinguisher located by the front door and mounted on the wall. A telephone line is available in the living room .Emergency supplies and Personal Protective Equipment supplies are stored in the garage and hallway closet. The applicant as an approved Infection Control Plan on file.

Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked kitchen drawer. Food supply is adequately stored in kitchen cabinets and consists of the can goods. The kitchen counters also had small appliances.
Continued on 809C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: OCEAN PEARL SENIOR LIVING	FACILITY NUMBER: 198320491
	VISIT DATE: 09/12/2024

NARRATIVE

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Resident & Staff Files:
The applicant is not handling the cash resources for residents. Records of staff and residents will be stored in locked cabinet by the kitchen area.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the resident's use all stored in the living room.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pool in the fenced area.

Fire clearance:
A Fire Clearance inspection was conducted on 07/12/2024 and noted the following special conditions of approval: “Only 1 bedridden client allowed due to there being no sprinklers in the home. Bedrooms 2,3, and 4 are approved for non-ambulatory and bedridden clients. Bedroom 1 approved for ambulatory client only.” Current license indicates 3 non-ambulatory and 3 bedridden. Applicant has submitted a request to the CAB analyst to change the ambulatory status and maintain the approved total capacity of 6.

Component III:
LPA Enriquez conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with Component III PowerPoint.

Continued on 809C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: OCEAN PEARL SENIOR LIVING	FACILITY NUMBER: 198320491
	VISIT DATE: 09/12/2024

NARRATIVE

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LPA Enriquez observed the following corrections:

-Operational Requirements - Technical Assistance: 1569.605 - Applicant does not have liability insurance at this time. Applicant indicated that he has received quotes and will be making a decision to purchase liability insurance as soon as possible. Applicant will email LPA at Hollie.Enriquez@dss.ca.gov a copy of the Liability Insurance as soon as possible.

-Food Service - Technical Assistance: 87555(b)(29) - LPA observed that the gas range in the kitchen was not igniting. Applicant contacted repair person at the time of the visit and will email LPA corrections at Hollie.Enriquez@dss.ca.gov soon as possible.

-Initial Application requested a capacity of six (6) individuals, of which three (3) may be non-ambulatory and three (3) may be bedridden. The Fire Clearance granted on 07/12/2024 noted the following special conditions of approval: “Only 1 bedridden client allowed due to there being no sprinklers in the home. Bedrooms 2,3, and 4 are approved for non-ambulatory and bedridden clients. Bedroom 1 approved for ambulatory client only.” At the time of the visit, Applicant submitted to CAU Analyst a new LIC200 to request and change in ambulatory status for: one (1) ambulatory, five (5) non-ambulatory of which one (1) may be bedridden and CAU has sent request to Fire Department for update; pending approval of update. Applicant will update LPA once ambulatory status has been updated on license application.

An exit interview was conducted, and a copy of this report has been furnished to Applicant Aviel Nahum. LPA Enriquez 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 assigned to their application.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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