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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603550
Report Date: 11/30/2023
Date Signed: 11/30/2023 04:28:12 PM


Document Has Been Signed on 11/30/2023 04:28 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:
11/30/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Crystene CharTIME COMPLETED:
02:15 PM
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Licensing Program Analysts (LPA) Elizabeth Irra conducted a subsequent annual inspection visit. LPA met with Crystene Char and discussed the purpose of today’s visit.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Physical Plant & Environment Safety: LPA toured facility grounds. Multiple carbon monoxide detectors were observed in each floor (tested and operable). Fire extinguishers are located throughout the facility and on each floor. Fire extinguishers were last services on 02/21/2023. Signal system was tested in the following rooms and were operational. Room 121, Room 222, Room 401, Room 415, Room 503, Room 504, Room 513, Room 602, Room 609 and Room 718. Hot water temperature measured within regulations. The hot water supply measured at the following temperatures: Room 121(109*), Room 222 (106.1*), Room 401 (106*) Room 415 (109.6*) Room 503 (110*), Room 504 (108*), Room 513 (107*), Room 602 (107*), Room 609 (109.1*) and Room 718 (108*). Bathrooms had non-skid surfaces and grab bars.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. The facility also has emergency water supply and emergency paper goods. Posted menu observed. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining area has adequate seating.

Health Related Services/Incidental Medical Services: The medications are stored inside locked carts located in the medication room. The facility utilizes an electronic program to document residents’ medication administration. LPA reviewed medication for R-5, R-6, R-7, R-8 and R-10.

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: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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