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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603319
Report Date: 07/10/2020
Date Signed: 07/10/2020 03:57:49 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BEVERLY HILLS TERRACEFACILITY NUMBER:
198603319
ADMINISTRATOR:STRIKS, AHARONFACILITY TYPE:
740
ADDRESS:1470 S ROBERTSON BLVDTELEPHONE:
3102733668
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:110CENSUS: DATE:
07/10/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Ella TIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Jade Jordan, and Jennifer Jones made an announced Tele visit, and met with the Administrator Ella Naygas conduct a Pre-Licensing evaluation on Friday 07/10/20, at 10:30 am.

An application was submitted to Community Care Licensing Department (CCLD) on 01/23/2020 for an initial application to serve Individuals for ages 60 years, and older. The requested capacity is for One hundred ten (110) non-ambulatory clients, zero (0) ambulatory clients, and zero (0) bedridden clients. Structure: The facility is a two-story building with a basement for garage. On the first floor, there are TV room, administrative office, laundry room, medication room, one common wheelchair shower room, kitchen, dining rooms, and Rooms#101 to #118, and rooms#123,124,125. On the Second floor, there are including small TV room, linen room and Rooms #201 to #235. Bedroom Residents: There shall be no more than two clients per bedrooms. Bedrooms #101-235 are for ambulatory / non-ambulatory clients. Bedrooms are equipped with two beds, night-stand, chair, lamp, and overhead lightning. Bedroom Staff: No bedrooms are used for awake staff. Bathrooms: Two (2) common bathrooms on the first floor,and second floor. Both have a working toilet, and wash basin. Bathroom located in all rooms have working toilets, wash basins, showers/bathtub with skid mat, and grab bars. There is one shower room that will accommodate non-ambulatory clients in a wheelchair. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads. Ample supply of linen is stored on the second floor in the linen closet, and clothing closet.Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted and readily available for review in living room area. Facility has a land line telephone located in the office area, 2 landlines upstairs. Two (5) fully charged fire extinguishers are located in dining room, and kitchen, left wing, right wing, and second floor serviced on 04/20/20.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
VISIT DATE: 07/10/2020
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Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils will be stored. Ample food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Dishwasher in kitchen properly installed and functioning. Smoke Detectors/Carbon Monoxide(s): There are electrical & connected smoke detectors; located in bedrooms, living room, and hallways. Carbon monoxide detector located in lobby, and both floors, and is operational. Appliances: Stove burners (gas or electric), oven, dishwasher, microwave, and washer/dryer are in working condition. There are two (3) refrigerators in the facility; all in the kitchen. The facility is equipped with central heat/air conditioning; and the water heater is in the garage. Toxins: Cleaning supplies, and toxins will be stored underneath kitchen sink, and in locked garage closet only accessible to staff. Water Temperature: Hot water was tested in bathroom #101, and temperature was 110 degrees within or above normal limits (105-120 degrees). Medication, First-Aid Kit & Book: Designated centrally stored medication will be locked and located in medication room cabinet. Sufficient bandages, one (1) tweezer, one (1) thermometer, one (1) First Aid Manual, and one (1) pair of scissors. Clients & Staff Files: Designated area for files will be located in locked office file cabinet. Applicant will not handle cash resources of clients. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 06/11/20 does advise of any delayed egress features and/or any locked perimeters.

Component III:

Component III was completed at the Pre-Licensing on Friday, 07/10/2020 at 3:30 pm. Information provided about how to operate the facility within substantial compliance. The following individuals, Ella, Administrator participated. When the applicant and administrator were asked if they have understood Title 22 they responded in the affirmative.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
VISIT DATE: 07/10/2020
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During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA by 07/31/2020. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.


1. Rm 115/103 need cabinet repainted
2.Elevator floor needs to be re-tiled
3. Rooms #225,#226 #235 need smoke detectors installed; Room #227 needs battery installed in smoke detector.

An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3