198602384-3-12-2024-11-AS-SDAY-D3ALFQ-20240312084328

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602384
Report Date: 03/07/2024
Date Signed: 03/12/2024 08:46:26 AM

Document Has Been Signed on 03/12/2024 08:46 AM - 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:	FOUNTAINVIEW AT GONDA WESTSIDE		FACILITY NUMBER:	198602384
ADMINISTRATOR:	OFRECIO, CHARLETTE		FACILITY TYPE:	741
ADDRESS:	12490 WEST FIELDING CIRCLE		TELEPHONE:	(424) 216-7788
CITY:	PLAYA VISTA	STATE: CA	ZIP CODE:	90094
CAPACITY:	286	CENSUS: 225	DATE:	03/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Keith McGevna		TIME COMPLETED:	04:00 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	Licensing Program Analyst (LPA),Sparkle Day conducted an unannounced annual visit. LPA met with Executive Director, Keith McGevna and the purpose of today's visit was explained. The community is licensed to operate as a Residential Care Facility for the Elderly (RCFE)/Continuing Care Retirement Community (CCRC). The community has an approved fire clearance for (216) Ambulatory, (70) Non- Ambulatory of which 20 may be bedridden. Facility is approved for secured perimeter. The community also has an approved hospice waiver for 25 residents. The community currently has total of 222 residents, 2 on hospice care, and 11 residents in memory care. Physical Plant During today’s visit, LPA and Executive Director toured the facility. The physical plant including floors 1-6, basement, both inside and outside. The facility has an enclosed pool on the 6th floor with a staff member stationed there during business hours. There is a salon, a gym, a card room and arts and craft for residents enjoyment. Apartments/Rooms LPA toured apartments which house residents with independent living capabilities. They include 1 or 2 bedrooms, 1-2 bathrooms, living room, kitchen, and laundry room. Residents have the option to furnish apartments with their own furniture. There is furnishings available if requested. LPA toured vacant rooms on each floor. Bathrooms Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and had a non-skid mat or chair in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. In rooms, the water temperature was measured and ranged between 115-and 119-degrees Fahrenheit. Kitchen LPA toured the commercial-size kitchen, located in the basement and first floor. All appliances were in good working order. LPA observed an adequate supply of cutleries, pots and pans that were well maintained and in good repair. The kitchen was observed to be within Title 22 regulations. LPA observed a 4-day supply of perishable foods and a 10-day supply of non-perishable foods. All knives and toxins are

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle Day	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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: FOUNTAINVIEW AT GONDA WESTSIDE	FACILITY NUMBER: 198602384
	VISIT DATE: 03/07/2024

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secured and inaccessible to residents. LPAs observed the food service areas and dining rooms, they were found to be clean and have ample seating for all residents. A menu is at the entrance of the dining room and residents can order daily what they would like. Food deliveries are made 5-6 days a week.
Common Areas The common areas living room, dining room, art room, theater room, private dining room, fitness room, pool area, patio areas and lounges were appropriately furnished allowing spacing by residents. LPA observed books, games, crafts and activities for residents. An event calendar is posted outside of activity rooms and theater. LPA observed ample lighting in all common spaces. Surveillance cameras were observed in the common areas. A comfortable temperature was maintained in the facility. Common areas were clean and clear of hazards; doorways were free of obstructions.
Safety LPA observed multiple fires extinguishers throughout the community that are fully charged. Fire doors close automatically when alarms are set off. Additionally, there is a sprinkler system throughout the facility. Last emergency drill was on 1/2024 The last emergency notification drill was on 1/2024. Facility has an intercom system for all resident’s apartments, rooms and common areas to be used for emergency communication. All exits and exit plans are posted and accessible to residents. All necessary safety postings were observed including emergency numbers, disaster plan. There is a working landline telephone. LPA inspected the First Aid Kit which contained all required items and a manual. Memory care unit is equipped with delayed egress. Elevators were last serviced on 1/20/22.
Infection Control LPA observed facilities infection control procedures, all guests need to check in at the main entrance. Residents and staff are screened daily. LPA observed necessary infection control posting in common areas including wear a mask, cough/sneeze etiquette, and maintain distance from others. All staff were wearing masks and majority of the residents were wearing masks.
Medications All medications in the memory care wing are secured inside the nurse’s station. Memory Care unit is located on the first and second floor of the building. Medications are locked and inaccessible to residents. LPA reviewed the MARs and medication for 7 residents.
Files LPA reviewed 20 client files and found they contained the required documents. LPA reviewed 15 staff files and found they contained the required documents, certification and training.
LPA reviewed the facilities Liability Insurance, which is good through 07/01/2023.
No Deficiencies were cited during todays visit
Exit interview conducted and a copy of this report was provided to Executive Director, Keith McGevna

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle Day	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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