198603550-7-8-2022-28-AS-KLOG-CG5RTV-20220708131857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603550
Report Date: 07/08/2022
Date Signed: 07/08/2022 01:19:22 PM

Document Has Been Signed on 07/08/2022 01:19 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	WEST PARK SENIOR LIVING		FACILITY NUMBER:	198603550
ADMINISTRATOR:	IRBY, LORI		FACILITY TYPE:	740
ADDRESS:	801 CYPRESS WAY		TELEPHONE:	(619) 296-9000
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	200	CENSUS: 117	DATE:	07/08/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lori Irby (Administrator)		TIME COMPLETED:	01:30 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 Analysts (LPAs) Kruz Long conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. An application was submitted on 03/14/22 for Initial License #198603550 for a Residential Care Facility for the Elderly to serve age range 60 and over. A tour of the facility contains 2 buildings: Building #1 has 2 floors, first floor containing a lobby, 5 offices, ballroom, staff break room, store, salon, 2 community men's restrooms, 2 community women's restrooms, pantry, mail room, kitchen, private dining room, dining room and a living room. Second floor is undergoing renovations used for storage. Building #2 contains 7 floors. First floor contains a medication room, activity room and 23 resident bedrooms each with it's own bathroom. From the second floor to the seventh floor: Each floor contains 24 resident bedrooms each with its own bathroom, laundry room, community restroom and an activity room. The following was observed: Passageways, walkways, driveways, steps and patios are free from obstructions. Front, back and side areas of free of hazards. Signal system in resident's bedrooms is operable. Resident bedrooms has all the necessary furnishings. Bathrooms have grab bars, working toilet, wash basin, bathtub/shower and non-skid tape/mats.The resident's bedrooms are spacious and easily accommodates the resident's furnishings. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Fire Extinguishers are located though out the entire facility. Dishes, cups and flat ware were inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored and locked in the kitchen. Food supply adequately stored in the kitchen. Smoke detectors and Carbon monoxide detectors are operational. Stove burners, oven, microwave, washer, and dryer working are operable. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at 0 zero degrees Fahrenheit. The residence is equipped with central air and heat. Toxins and cleaning supplies are stored in the second floor of Building #1. Water temperature tested in various resident bathrooms measured within Title 22 guidelines. Continue to LIC809C....

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WEST PARK SENIOR LIVING	FACILITY NUMBER: 198603550
	VISIT DATE: 07/08/2022

NARRATIVE

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A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual. Staff and resident files are stored in the Activity office. Each floor has a land line readily available for resident use. The facility has board games, books, and other recreational materials for the residents use. There are no pool or large bodies of water on the premises. Fire clearance was approved on 01/28/22.

Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

During the pre-licensing inspection, LPA did not observe items which do not comply with applicable laws and regulations

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 Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

LIC809 (FAS) - (06/04)

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