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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607196
Report Date: 08/03/2021
Date Signed: 08/03/2021 03:03:38 PM

Document Has Been Signed on 08/03/2021 03:03 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BRENTWOOD ON SUNSETFACILITY NUMBER:
197607196
ADMINISTRATOR:SAM MAGHAZEIFACILITY TYPE:
740
ADDRESS:11580 SUNSET BLVD.TELEPHONE:
(310) 472-4316
CITY:LOS ANGELESSTATE: CAZIP CODE:
90049
CAPACITY: 6CENSUS: 4DATE:
08/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Sam MaghazeiTIME COMPLETED:
03:00 PM
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On 08/03/2021 Licensing Program Analyst (LPA) Troy Agard conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival at the facility, LPA Agard conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for six (6) non-ambulatory residents, of which one (1) may be bedridden and an approved hospice waiver for two (2) residents. Currently, there are no residents on hospice present during today’s visit.

LPA met with the administrator and both toured the inside and outside grounds of the facility. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log and temperature log was observed. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is in the back patio. LPA observed required postings at the front of the facility.

LPA did not observe newly admitted residents or newly hired staff. The facility has two out of four residents with memory care needs. Potentially dangerous items, including sanitizers, are kept inaccessible to residents with dementia.

All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Furniture in the common area were in good repair. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. The water temperature measured at 120.2 F. A comfortable temperature

Continued on 809C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2021
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRENTWOOD ON SUNSET
FACILITY NUMBER: 197607196
VISIT DATE: 08/03/2021
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was maintained in the facility.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage cabinet. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. One fire extinguisher was observed in the kitchen area.

Outside grounds were toured. LPA observed a cascading pond in the backyard of the facility. The widest part of it is about 5 feet and the length is about 8 feet. The pond is about 2 feet deep with water that is inaccessible to residents in care. Pond was gated with hard wires. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

No deficiencies were cited during this visit.

One technical advisory was discussed with Administrator

An exit interview was conducted, and a copy of this report was provided to Licensee/Administrator.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC809 (FAS) - (06/04)
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