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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603580
Report Date: 11/03/2022
Date Signed: 11/08/2022 10:47:44 AM


Document Has Been Signed on 11/08/2022 10:47 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:BEVERLY HILLS SENIOR CAREFACILITY NUMBER:
198603580
ADMINISTRATOR:RIVAS, JENNIFERFACILITY TYPE:
740
ADDRESS:1015 S. ORANGE GROVE AVETELEPHONE:
(323) 933-8271
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:45CENSUS: 43DATE:
11/03/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Patria DufrenneTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an announced pre-licensing visit at the facility. LPA met with Applicant Patria Dufrenne and explained the reason for the visit.

Facility has a fire inspection clearance conducted on 9/19/22 for 39 non-ambulatory and 6 bedridden residents over the age of 60 years old. Facility is a three-level facility which includes: Street level: Kitchen, food storage area, laundry room and parking area. First level: Lobby, dining room, 2 storage rooms, community restroom, office, 9 resident bedrooms (each with a bathroom or a shared bathroom), and a medication room. Second level: Dining room, 15 resident bedrooms (each with a bathroom or a shared bathroom).

LPA conducted a tour of the facility with Applicant Patria Dufrenne and observed the following:

Outdoor facility was observed in good repair. No large bodies of water were observed. Commercial kitchen was observed to be clean and sanitized, sufficient food was observed for at least 2 days worth of perishables and 7 days of non- perishables. Refrigerator(s) temperature was observed under 40 degrees F., and freezer(s) temperature was observed under 0 (zero) degrees F. All rooms have sufficient lighting, furniture, and bedding. Water temperature was measure in each resident's bathroom and tested between 106 - 120 degrees F., which is within the required 105 - 120 degrees F. Facility ha a sprinkle fire system and carbon monoxide detectors were observed in each room. Skid strips/mats were observed in resident bathrooms. Medication room was locked and inaccessible to residents as well as cleaning supplies and other cleaning agents/ toxins. All common areas were observed in good repair, with sufficient furniture. First Aid kit was reviewed and contained all the required items. Facility is following infection control protocols throughout the facility.

(CONTINUED ON LIC 809C)
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS SENIOR CARE
FACILITY NUMBER: 198603580
VISIT DATE: 11/03/2022
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PPE supplies were observed sufficient for 30 days.

Physical plant was cleared. Facility met the physical plant requirements as required per California Code of Regulations Title 22 Division 6.

Component III was also completed at the time of the visit and all required documents for Licensing were discussed.

A copy of this report will be shared with Central Applications Bureau (CAB).

If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

Exit interview conducted and a copy of this report was provided to Applicant Patria Dufrenne.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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