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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603319
Report Date: 07/20/2021
Date Signed: 07/20/2021 02:07:50 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:
(818) 293-2007
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:110CENSUS: 85DATE:
07/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Clifford JohnsonTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Clifford Johnson, Assistant Administrator and the purpose of today’s visit was explained. The facility is licensed to serve 110 residents for elderly care.

There are currently have 85 resident age 60 and over. Approved for 110 Non-Ambulatory and 15 Hospice
Waivers. The facility is a two story structure located. It consists of the following: bedrooms, bathrooms, two TV rooms, dining room, kitchen and patio area, medicine and laundry area.

LPA and administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. Residents rooms were in good condition and observed. Walls and floors were in good repair. Bed linens and bath towels were adequately stocked at the time of visit. Restrooms were found to be within Title 22 regulations and were clean and operational. The water temperature in Restroom #1 105 F and #2 105.1 F. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguishers was charged, smoke detectors and Carbon Monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LIC 808-C is on the next page
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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 2
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: 07/20/2021
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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the report was provided to Clifford Johnson, Administrator.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC809 (FAS) - (06/04)
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