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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600215
Report Date: 09/16/2021
Date Signed: 09/16/2021 04:44:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MT. SINAI GUEST HOMEFACILITY NUMBER:
198600215
ADMINISTRATOR:DECOHEN, GERALDINEFACILITY TYPE:
735
ADDRESS:1800 12TH AVENUETELEPHONE:
(323) 737-7264
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:6CENSUS: 2DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Uorice De CohenTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Uorice De Cohen and explained the purpose of today's visit.

This is an ARF with a capacity of 6. The facility is licensed to serve 3 ambulatory clients and 3 non ambulatory clients. Approved Hospice Waiver for 1 client. The following was inspected and toured: A tour of the two-story facility includes: (First floor) Living room, detached garage/storage/office, dining room, kitchen, laundry room, three client bedrooms, one staff bedroom, two bathrooms, one project room, and a den. (Second floor) contains three client bedrooms and one bathroom.

The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms and hallways.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Clients are able to use a designated isolation room that will be used as isolation rooms if a COVID-19 positive case should arise.
  • 30 day supply of medication for clients
  • Facility has an adequate amount of PPE and facility has enough PPE for 60 days.
  • Clients were socially distanced according to local public health guidelines.
  • Clients were wearing masks.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed (including paper goods, utensils etc).
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MT. SINAI GUEST HOME
FACILITY NUMBER: 198600215
VISIT DATE: 09/16/2021
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According to the California Code of Regulations, LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator Uorice De Cohen and copy of report provided.

SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC809 (FAS) - (06/04)
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