198602384-1-6-2023-11-AS-WGIS-CMU2SS-20230106163937

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602384
Report Date: 12/21/2022
Date Signed: 01/06/2023 04:39:41 PM

Document Has Been Signed on 01/06/2023 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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: 216	DATE:	12/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	James Mackay/Clarissa Townes		TIME COMPLETED:	03:00 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), Wendy Gibbs, conducted an unannounced annual visit, with the primary focus on infection control using the CARE tool. LPA met with Executive Director, James MacKay and explained the purpose of today's visit. 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 216 residents, 2 of them on hospice care, and 11 residents in memory care. Physical Plant During today’s visit, LPA, Director of Health Services, Clarissa Townes and Community Care Coordinator, Social Worker Noel Powell toured the facility. The physical plant including floors 1-6, basement, both inside and outside. Apartments/Rooms LPA toured apartments which house residents with independent living capabilities. They include bedrooms and bathrooms, some had living rooms, kitchens, laundry rooms, and all had the required furniture, equipment, and supplies. LPA toured rooms and observed they had the required furniture, including beds, nightstands with a lamp, dresser, chair, and closet space. Residents have the option to furnish apartments as desired. All beds have the required linens including mattress pad, fitted sheets, blankets, comforter and pillows. Bathrooms Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower 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 112.8-and 119.6-degrees Fahrenheit.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FOUNTAINVIEW AT GONDA WESTSIDE	FACILITY NUMBER: 198602384
	VISIT DATE: 12/21/2022

NARRATIVE

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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 that were well maintained and in good condition. 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 securely locked and inaccessible to residents. LPAs observed the food service areas and dining rooms, they were clean and had ample seating for all residents. Common Areas The common areas living room, dining room, art room, theater room, private dining room, fitness room, pool area, patio areas & bar room were appropriately furnished allowing spacing by residents. LPA observed ample lighting in all common spaces. Surveillance cameras were observed in the common areas on the floors toured. Common areas were clean and clear of hazards; doorways were free of obstructions. LPA observed an employee stationed in the fitness/pool area.
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 on10/21/2022 and the last. The last emergency notification drill was on 12/09/2022. All exits and exit plans are posted and accessible. 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.
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 locked 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 eMARs and medication for 8 residents.
Files LPA reviewed 21 resident files. All files contained the necessary documentation. LPA reviewed 6 staff files. All files contained the necessary documentation.
LPA reviewed the facilities Liability Insurance, which is good through 07/01/2023.
No Deficiencies cited.
Exit interview conducted and a copy of the report was given Executive Director, James Mackay.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

LIC809 (FAS) - (06/04)

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