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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600525
Report Date: 04/26/2023
Date Signed: 04/26/2023 05:11:28 PM

Document Has Been Signed on 04/26/2023 05:11 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:WESTSIDE MANORFACILITY NUMBER:
198600525
ADMINISTRATOR:CHAVEZ, GABRIELAFACILITY TYPE:
735
ADDRESS:4836 WEST WASHINGTON BLVD.TELEPHONE:
(323) 937-4506
CITY:LOS ANGELESSTATE: CAZIP CODE:
90016
CAPACITY: 136CENSUS: 94DATE:
04/26/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:09 AM
MET WITH:CHAVEZ, GABRIELATIME COMPLETED:
05:09 PM
NARRATIVE
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On 04/26/2023 at 8:11 AM Licensing Program Analyst (LPA) David España conducted an unannounced annual continuation visit to the facility. The purpose of today’s visit was to conduct a required 1 year annual inspection. LPA met with Administrator Gabriela Chavez and explained the reason for today's visit.

At 8:20 AM LPA España and staff went to the Medication Room located on the 1st floor of the facility and met with Med Tech staff regarding the medication procedures. LPA España and staff stated Med Room is kept locked and is not accessible to residents. LPA España observed that medications are centrally stored in the Medication Room and observed and reviewed four residents MARs. LPA España interviewed staff and specified residents’ medications are prepared one hour prior to dispensing the medications and are color coded green (e.g., morning) and blue (evening).



LPA España interviewed staff, and stated each resident has a MARs for the Month which list all residents’ medications per physician orders. LPA España interviewed staff which has stated that they (staff) do an assessment of the MARs for the date, time, medication, dosage and frequency. LPA España interviewed, observed, the protocol in place for all of the residents’ medications from the original container into a clear plastic cup with the resident’s name on it and places a clear lid on the clear plastic cup. LPA España interviewed, observed, the protocol of the clear plastic cup which are then placed into a tray that has a location for each individual resident’s medication cups with the names of the resident visible to the staff. LPA España interviewed, observed, the protocol of all medication cups is prepared and placed in the tray, the tray is placed in plastic container in order to transport the medications to the residents without spilling, mixing or contaminating the medications. LPA España interviewed, observed, the protocol which provides the resident their medications, prior to giving the medications, the staff is trained to pick up the Medication Cup and verify the medication is for the correct residents before administering it. At 9:36 AM LPA España and staff observed that the staff removes the lid off the clear plastic cup and places the residents’ medications into a clean cup and gives the medication to the resident to take with a cup of water. The staff verifies the resident took their medications and places the empty clear plastic cup back into the tray and moves on to the next resident.
staff indicated that residents’ medications are prepared.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 04/26/2023 05:11 PM - It Cannot Be Edited


Created By: David Espana On 04/26/2023 at 04:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WESTSIDE MANOR
FACILITY NUMBER: 198600525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(1)


This requirement is not met as evidenced by: 80019 Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department or
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA observed S2 in lobby who did not have verification of a criminal record clearance on file or transfer, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2023
Plan of Correction
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Licensee shall ensure that all staff have a criminal record clearance or transfer to the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:David Espana
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


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Page: 2 of 13
Document Has Been Signed on 04/26/2023 05:11 PM - It Cannot Be Edited


Created By: David Espana On 04/26/2023 at 04:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WESTSIDE MANOR
FACILITY NUMBER: 198600525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80021(a)(2)
Water Supply Clearance
(2) Subsequent to initial licensure, the licensee shall provide evidence of a bacteriological analysis of the private water supply as frequently as is necessary to ensure the safety of the clients, but no less frequently than specified in the following table:
For a licensed capacity of 6 or fewer analysis is required at initial licensing and subsequent analysis is not required unless evidence supports the need for such analysis to protect clients.
For a licensed capacity of 7 through 15 analysis is required at initial licensing and subsequent analysis is required annually.
For a licensed capacity of 16 through 24 analysis is required at initial licensing and subsequent analysis is required semiannually.
For a licensed capacity of 25 or more analysis is required at initial licensing and subsequent analysis is required quarterly.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:David Espana
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


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Document Has Been Signed on 04/26/2023 05:11 PM - It Cannot Be Edited


Created By: David Espana On 04/26/2023 at 04:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WESTSIDE MANOR
FACILITY NUMBER: 198600525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:David Espana
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 04/26/2023 05:11 PM - It Cannot Be Edited


Created By: David Espana On 04/26/2023 at 04:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WESTSIDE MANOR
FACILITY NUMBER: 198600525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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4
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:David Espana
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


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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: WESTSIDE MANOR
FACILITY NUMBER: 198600525
VISIT DATE: 04/26/2023
NARRATIVE
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Per Title 22 Regulations, there were deficiencies observed and cited during the visit.

Exit Interview Conducted and a copy of report was provided to Administrator Gabriela Chavez.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
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