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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603550
Report Date: 11/28/2023
Date Signed: 11/28/2023 03:17:00 PM


Document Has Been Signed on 11/28/2023 03:17 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
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: 112DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Claudia RuizTIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Claudia Ruiz and Crystene Char and discussed the purpose of today’s visit.

This facility is approved for (81) ambulatory and (119) non-ambulatory residents (of which 10 may be bedridden). This facility has an approved hospice waiver for (15) residents. The following bedrooms are approved for bedridden residents: #206,207,208,209,210,106,107,108,109 and 110.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Facility has an Infection Control Plan in place.

Operational Requirements: This facility is approved for (81) ambulatory and (119) non-ambulatory residents (of which 10 may be bedridden). This facility has an approved hospice waiver for (15) residents. The following bedrooms are approved for bedridden residents: #206,207,208,209,210,106,107,108,109 and 110.

Staffing: Facility is adhering to staffing requirements.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator/S-1 through Staff #6 (S-6). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights.

Refer to LIC 809C for the continuation of this report.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WEST PARK SENIOR LIVING
FACILITY NUMBER: 198603550
VISIT DATE: 11/28/2023
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Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #10 (R-10). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Appraisal/Needs and Services Plan, Resident Rights were observed.

Resident Rights-Information: Resident rights are posted and included in Resident files.
Planned Activities: Facility has an Activities Director and Activities Assistant.
Disaster Preparedness: The facility has a Disaster Preparedness plan in place.

The following domains remain pending:
  • Physical Plant & Environment Safety
  • Food Service
  • Health Related Services/Incidental Medical Services

Exit interview conducted, copy of appeal rights and a copy of this report was provided to Crystene Char.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
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