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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603220
Report Date: 09/02/2023
Date Signed: 09/02/2023 05:57:15 PM


Document Has Been Signed on 09/02/2023 05:57 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:CITY VIEW LA, LLCFACILITY NUMBER:
198603220
ADMINISTRATOR:GINSBURG, MENDYFACILITY TYPE:
740
ADDRESS:515 N LA BREA AVETELEPHONE:
(323) 938-2131
CITY:LOS ANGELESSTATE: CAZIP CODE:
90036
CAPACITY:166CENSUS: 72DATE:
09/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Marcia McKay - Wellness DirectorTIME COMPLETED:
03:43 PM
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On 09/02/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Wellness Director Marcia McKay. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (166) non-ambulatory elderly adults of ages 60 and above. Currently, the facility has (47) residents in Assisted Living, (25) in Memory Care (3) in hospice care. The facility is approved for (14) hospice residents.

The facility is a six-story structure located in a commercial neighborhood. It consists of the following: (21) resident bedrooms in Memory Care and (71) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, an activity room, a dining area, a private dining room, a kitchen, a rooftop patio, a lobby, (8) public restrooms, a gym, and subterranean parking.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #204, #211, #300, #316, #407, #503, and #507. All call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.7 – 108.9 degrees F. A comfortable temperature was maintained in the facility at 72-79 degrees F.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately.

Evaluation Report continues LIC 809-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2023
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: CITY VIEW LA, LLC
FACILITY NUMBER: 198603220
VISIT DATE: 09/02/2023
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Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. A review of the Medication Administration Records (MAR) was observed to be maintained in order and accurate. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA conducted an audit of resident #1-#6 (R1-R6) service files, and staff #1-#6 (S1-S6) personnel files. LPA conducted (3) resident and (3) staff interviews. The facility maintains a current liability insurance effective 12/01/22 through 12/01/23. The facility has is current on Community Care Licensing (CCL) license annual dues.

DEFICIENCIES:
During staff file review between 11am - 1pm, the following required items were not in the files:
  • (5) out of (6) staff #1, #2, #4, #5, and #6 did not have have current CPR/First aid on file.
  • (3) out of (6) staff #1, #2, #4 did not have proof of mandatory medical training.


According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Marcia McKay and a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2023 05:57 PM - It Cannot Be Edited

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: CITY VIEW LA, LLC
FACILITY NUMBER: 198603220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General - All RCFE staff...shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above. LPA identified staff #1, #2, #4, #5 #6 did not a valid or current CPR/First Aid on file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2023
Plan of Correction
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The administrator is to obtain current first aid certificates for staff #1, #2, #4, #5, and #6 and will create a plan to ensure that ensure that caregiver staff who assist residents with personal activities of daily living receive annual first aid training. Proof of correction will be submitted to CCL via email at ernand.dabuet@dss.ca.gov. The administrator may ask for an extension if more time is needed via email.
Type B
Section Cited
HSC
1569.625(b)(c)(1-5)
1569.625 Staff training; legislative findings; contents (b) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 10 hours of training within the first four weeks of employment and four hours annually thereafter. This training shall be administered on the job, or in a classroom setting, or any combination of the two. The department shall establish, in consultation with provider organizations, the subject matter required for this training.
(c) The training shall include, but not be limited to, the following: (1) Physical limitations and needs of the elderly. (2) Importance and techniques for personal care services. (3) Residents' rights. (4) Policies and procedures regarding medications. (5) Psychosocial needs of the elderly.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above. LPA identified staff #1, #2, #4 did not have the required medical training as proof of completion in each file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2023
Plan of Correction
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The Administrator is to coordinate training or train staff and required trainings. Facility Administrator to submit the following to ernand.dabuet@dsss.ca.gov by POC due date: 09/23/23 sign-in sheet with staff/participant names and signatures, date of training, topic of training, duration of the training and curriculum used for the training.
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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2023
LIC809 (FAS) - (06/04)
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