198603319-9-9-2023-11-AS-EDAT-CVHSYD-20230909141723

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603319
Report Date: 09/09/2023
Date Signed: 09/09/2023 02:17:52 PM

Document Has Been Signed on 09/09/2023 02:17 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:	BEVERLY HILLS TERRACE		FACILITY NUMBER:	198603319
ADMINISTRATOR:	STRIKS, AHARON		FACILITY TYPE:	740
ADDRESS:	1470 S ROBERTSON BLVD		TELEPHONE:	(310) 273-3668
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	110	CENSUS: 68	DATE:	09/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	BELLA NAYGAS		TIME COMPLETED:	01:39 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	On 09/09/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Bella Naygas. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (110) non-ambulatory elderly adults of ages 60 and above. Currently, the facility has (68) residents of which (0) are in hospice care. The facility is approved for (15) hospice residents. The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (55) resident bedrooms. Each room has a bathroom, an activity room, a dining area, a library, a kitchen, a courtyard patio, a lobby, (2) public restrooms, 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: #113, #115, #206, #209, #212, and #227. All call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.0 – 106.9 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. 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. Evaluation Report continues LIC 809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2023

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: BEVERLY HILLS TERRACE	FACILITY NUMBER: 198603319
	VISIT DATE: 09/09/2023

NARRATIVE

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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 has is current on Community Care Licensing (CCL) license annual dues.

DEFICIENCIES:
During plant inspection between 12pm - 12:40pm, the following were observed:
· Room #212 did not have working toilet flapper in working condition.
· Interior door jambs for common shower area is filled with rust and mold.

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 Bella Naygas 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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/09/2023 02:17 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: BEVERLY HILLS TERRACE	FACILITY NUMBER: 198603319
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(6)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation), the licensee did not comply with the section cited above. LPA identified room #212 toilet flapper not working condition and shower door jamb filled with rust and mold. This violation] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/09/2023
	Plan of Correction
1 2 3 4	The licensee agreed to have the facility in good repair at all times. Room #212 toilet flapper will be repaired/replaced. The shower door jamb will be repaired/replaced. Proof of correction must be sent to LPA Dabuet: ernand.dabuet@dss.ca.gov by POC: 10/09/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2023

LIC809 (FAS) - (06/04)

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