198603723-6-18-2024-28-AS-AGOZ-D6CRPE-20240618131148

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603723
Report Date: 06/18/2024
Date Signed: 06/18/2024 03:15:20 PM

Document Has Been Signed on 06/18/2024 03:15 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:	BEVERLY HILLS SENIOR CARE		FACILITY NUMBER:	198603723
ADMINISTRATOR:	ORDONEZ, DANA		FACILITY TYPE:	740
ADDRESS:	1015 S ORANGE GROVE AVE		TELEPHONE:	(323) 933-8271
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90019
CAPACITY:	45	CENSUS: 45	DATE:	06/18/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Dana Ordonez		TIME COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. LPA met with Administrator Dana Ordonez.

An application was submitted to CCLD for a Change of Ownership of a Residential Care Facility for the Elderly, ages 60 years and older. The fire clearance has been approved for a capacity of 45 residents, 39 ambulatory and 6 bedridden. Bedrooms #101-103 and #105 are approved for bedridden. The hospice waiver is approved for 20 residents.

Infection Control: The licensee has developed an Infection Control Plan and designated a lead staff to conduct training. Facility has sufficient PPE supplies and will provide on-going training to staff on infection control.

Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 3 residents residing at the facility.

Structure/Physical Plant: The 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). Outdoor facility was observed in good repair. No large bodies of water were observed. Water temperature was measure in each resident's bathroom and tested between 106 - 120 degrees F., which is within Title 22 regulations. Facility ha a sprinkle fire system and carbon monoxide detectors were observed in each room. Skid strips/mats and grab bars were observed in resident bathrooms. Cleaning supplies and other cleaning agents/ toxins were locked and inaccessible to residents. All common areas were observed in good repair, with sufficient furniture. Facility is following infection control protocols throughout the facility.

(CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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: 198603723
	VISIT DATE: 06/18/2024

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Food Service: There is a sufficient food supply of 2 day perishable and at least a week of non-perishable food maintained at the facility. Commercial kitchen is kept clean and sanitary. All the appliances were in working order. Sufficient amount of tableware, dishes, and utensils are observed. The knives and sharps are stored and locked in a cabinet. 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.

Staff and Residents files: Staff and Residents files are stored and maintained in the facility office.

Resident Rights/Information: Resident rights, Resident councils, and complaint posters are posted in a prominent area.

Planned Activities: The facility has sufficient space to accommodate indoor and outdoor activities.

Incidental Medical and Dental: Medications are centrally stored and locked inside medication room. The first aid kit contains all the required supplies along with the current first aid manual.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.

Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice.

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 Administrator Dana Ordonez.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

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