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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607196
Report Date: 08/10/2024
Date Signed: 08/10/2024 11:33:50 AM

Document Has Been Signed on 08/10/2024 11:33 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:BRENTWOOD ON SUNSETFACILITY NUMBER:
197607196
ADMINISTRATOR/
DIRECTOR:		SAM MAGHAZEIFACILITY TYPE:
740
ADDRESS:11580 SUNSET BLVD.TELEPHONE:
(310) 472-4316
CITY:LOS ANGELESSTATE: CAZIP CODE:
90049
CAPACITY: 6CENSUS: 3DATE:
08/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:28 AM
MET WITH:Sam Maghazei-AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:33 AM
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On 8/10/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Sam Maghazie /Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) elderly adults ages 60 and above, of which (6) can be non-ambulatory. The facility has an approved hospice waiver for (2) and (1) Bedridden for room #3.

The home consists of a total of 6 bedrooms and 6 bathrooms, including 4 resident bedrooms, 4 resident bathrooms, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably.



LPA Iniguez and the Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (3) bedrooms and (2) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 113.5°F to 115.2°F, and the room temperature ranged from 76°F to 78°F.

The evaluation report continues on the next page, LIC 809-C, providing further details of the inspection findings.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BRENTWOOD ON SUNSET
FACILITY NUMBER: 197607196
VISIT DATE: 08/10/2024
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During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 4/10/24.

A review of (3) residents' service files and (3) staff personnel files was maintained in order. Facility does not use Medication Administration Records (MARs).

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be email to LPA. Facility Annual Fess current.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-No smoke detector on client room and hallway.

-Unlocked cleaning agents in one of resident’s bathroom.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared.


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Sam Maghazie / Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2024 11:33 AM - It Cannot Be Edited


Created By: Alfonso Iniguez On 08/10/2024 at 11:20 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BRENTWOOD ON SUNSET
FACILITY NUMBER: 197607196

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) , the licensee did not comply with the section cited above in not having smoke detectors in a resident's bedroom and hallway which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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Licensee will ensure facility has all smoke detectors in place. As plan of correction, licensee will place missing smoke detectors and send a picture as proof to LPA via email before POC due date.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) , the licensee did not comply with the section cited above in having cleaning agents unlocked in one of the resident's bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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Licensee will ensure all cleaning agents are locked at all times. As part of Plan of Correction, licensee will informed family reagrding cleaning agents not to be place in an unlocked area, also licensee will re-train all facility staff about keeping clenaing agents locked at all times. A proof of email to families and copy of staff training will be sent to LPA via email before POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2024


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