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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603550
Report Date: 04/13/2023
Date Signed: 04/13/2023 11:24:00 AM


Document Has Been Signed on 04/13/2023 11:24 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:WEST PARK SENIOR LIVINGFACILITY NUMBER:
198603550
ADMINISTRATOR:IRBY, LORIFACILITY TYPE:
740
ADDRESS:801 CYPRESS WAYTELEPHONE:
(626) 339-5426
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:200CENSUS: 113DATE:
04/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Lori IrbyTIME COMPLETED:
11:29 AM
NARRATIVE
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LPA Lopez made unannounced visit to facility and met with Administrator Lori Irby. Purpose of visit was discussed.

LPA toured random floors of facility and inspected food supplies.

LPA explained to administrator that facility has not complied with reporting requirements on more than one occasion. On 3/18/2023 a resident cut self and it was not reported to the department until 3/29/2023. Past the 7 day requirement. On 03/25/2023 a Death report was submitted without a name of resident. Corrected Death report was submitted on 04/03//2023 past the 7 day requirement.

No health or safety hazards were observed during today's visit.

The reporting delays pose health and safety hazard to residents in care.

Deficiencies cited on 809D
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
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


Document Has Been Signed on 04/13/2023 11:24 AM - 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: WEST PARK SENIOR LIVING
FACILITY NUMBER: 198603550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2023
Section Cited

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87211 (a) (1) (b) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. (1) This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

This requirement is not met by evidence of:
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Administrator will send LPA a written plan on how facility will correct the late reporting and conduct in service with all staff on reporting requirements and send signed roster with dates, length, instructor, and topics covered by POC
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Facility has not complied with reporting requirements on more than one occasion. On 3/18/2023 a resident cut self and it was not reported to the department until 3/29/2023. Past the 7 day requirement. On 03/25/2023 a Death report was submitted without a name of resident. Corrected Death report was submitted on 04/03/2023 past the 7 days

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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
LIC809 (FAS) - (06/04)
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