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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608200
Report Date: 10/18/2021
Date Signed: 10/18/2021 04:17:19 PM

Document Has Been Signed on 10/18/2021 04:17 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ALTA VISTA GARDENSFACILITY NUMBER:
197608200
ADMINISTRATOR:STACI MARMERSHTEYNFACILITY TYPE:
740
ADDRESS:829 NORTH ALTA VISTA BLVD.TELEPHONE:
(323) 937-1940
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 70CENSUS: 70DATE:
10/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Staci MarmerTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility at 9:30am to conduct a One (1) year
Required Infection Control visit. LPA meet with the Administrator Staci Marmer and explained the
purpose of this visit.

A tour of the physical plant was conducted at 9:38am and the following was observed:

The facility has one main entrance being used, there are required Covid-19 prevention signage (hand
washing, coughing etiquette and physical distancing) posted throughout the facility. The PPE screening
station is located inside the medication room located at the entrance of the facility. PPE is readily accessible a thermometer, gloves, mask, and sign in sheet at the time of visit. Hand sanitizer is located on the wall at the entrance near the medication room and throughout the facility posted on the wall. The facility maintains a comfortable temperature of 72 degrees.
The facility has an approved mitigation plan on file.
Medication: At 9:38am LPA observed the medication room, located at the entrance of the building. The medication room observed to be locked when unattended by staff or management in the office. The medications are stored in open faced cupboards, LPA observed medication and PPE stored in the medication office and a First Aid Kit and manual. Medication is prepared in the medication room and dispensed to residents.
Kitchen: At 9:47am LPA observed the kitchen to be clean and clear from obstruction. Food storage and
preparation areas are clean and inaccessible to pests. The kitchen has a dining room adjoining the kitchen that was observed to be locked and inaccessible to residents. LPA observed four (4) refrigerator to be storing Perishable food, meats, and vegetables. The kitchen door also has a lock which was observed to be open but is locked when staff is unattended in the kitchen. LPA observed kitchen drawers to be without locks used to store sharps. Toxins observed to be under the kitchen sink, kitchen staff is stationed in the kitchen during shift or the kitchen is closed and locked when unattended by kitchen staff and inaccessible to residents.
(Continued on LIC 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ALTA VISTA GARDENS
FACILITY NUMBER: 197608200
VISIT DATE: 10/18/2021
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Bedrooms: LPA at 10:06am observed bedrooms to have sufficient lighting and are properly furnished and
observed to be clean and have appropriate bedding and linens.
Bathrooms: At 10:06am LPA observed the bathrooms located in the bedrooms to half baths and the rooms that have a full bath showers are not being used all showers are conducted in the shower room located near the kitchen. LPA observed appropriate grab bars and non-slip skid mats in the bathtub. The hot water temperature measured in range from 105.6 through 110.3 degrees Fahrenheit. Bathrooms observed to be clean and have sufficient soap and paper towels hand towels are not shared. The second shower room is in the memory care unit.

Living, dining room and common areas: At 10:22am observed living room to have television, chairs seating with sufficient lighting. LPA observed to be clean and in good repair and free from obstruction. The dining room observed to have sufficient lighting, chairs, and tables for seating. LPA observed activity supplies to be stored in a cabinet in the office/medication room.
Basement/Laundry Room/ Storage Rooms: At 10:33am LPA observed the laundry room to be clean and clear from obstruction. Laundry soap, toxins, and poisons observed to be locked and stored in the housekeeping supply cabinet located in the in the basement. LPA observed first storage room located in the basement to be stocked with PPE, toiletries, and incontinent supplies. The second storage has extra personal care items (shampoo, body wash lotion etc.). On the second-floor patio area, has a shed that is storing mop buckets and other cleaning equipment observed to be locked and inaccessible to residents. The emergency food is also stored in the basement in a locked storage room supplied with enough water, canned food, and non-perishables items

Backyard: At 10:54am LPA observed the back yard and area around the facility observed to be clean and clear of debris. The facility has multiple seating areas for lounging on the second-floor patio area with an owing with table and chairs for seating. The facility has a shaded front area with tables and chair for seating.
At 11:15am the fire alarm system was tested and observed to be working, it is hard wired and
inter-connected. The facility has Fire Extinguishers located throughout the facility all have a service tag dated
November 06, 2020. No bodies of water observed on the property.

There are no deficiencies to report during this time. Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
LIC809 (FAS) - (06/04)
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