<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205367
Report Date: 07/28/2021
Date Signed: 07/29/2021 09:10:15 AM

Document Has Been Signed on 07/29/2021 09:10 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:WESTCHESTER VILLAFACILITY NUMBER:
198205367
ADMINISTRATOR:EVANGELINE AGATEPFACILITY TYPE:
740
ADDRESS:220 W. MANCHESTER BLVD.TELEPHONE:
(310) 673-1093
CITY:INGLEWOODSTATE: CAZIP CODE:
90301
CAPACITY: 174CENSUS: 89DATE:
07/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Evangeline AgatepTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Cardenas called Administrator, Evangeline Agatep; LPA conducted a risk assessment over the telephone and explained the purpose of todays visit. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

Facility is licensed to serve 174 non-ambulatory residents ages 60 and above. Dementia special program- Hospice Waiver approved for three (3) residents. LPA met with the administrator and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked.

The above facility is a two-story commercial building. the facility consisted of the following: The first floor Lobby/receptionist area, business office/ medication room/ record office, Administrator's office, 34 bedrooms and bathrooms, emergency supply room, beauty salon, storage rooms, 3 living rooms, dining rooms, kitchen, resident's private laundry room/commercial laundry room, activity room, recreation/activity director's office, men and women public restrooms, employee's lounges, men and women employee's restrooms, linen room, housekeeping supply room, patios, shaded area, indoor/outdoor activity area, and gated security parking lot. The second floor consisted of: 52 resident's bedrooms and bathrooms, men and women public restrooms, resident's private coin laundry room, TV room, library/living room, game room, storage rooms.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, and records of daily Covid-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional 30-day supply of PPE was observed. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the common space on first floor/ outside shaded area located on the front of the facility. LPA observed all staff wear a face covering. LPA observed required

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2021
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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: WESTCHESTER VILLA
FACILITY NUMBER: 198205367
VISIT DATE: 07/28/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
postings throughout the facility. Resident rooms were inspected. Beds in shared bedrooms are 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Resident bathrooms were checked toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. The water temperature measured between 105 degrees to 120 degrees F in resident bathrooms that were inspected. Comfortable temperature 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. Toxins were kept in a locked storage. Centrally stored medications were observed to be kept safe and locked and inaccessible to residents in care. The First Aid kit was available and fully stocked with tweezers, scissors, and non-contact thermometer. The facility is equipped with fully charged Fire Extinguisher throughout the facility; fire extinguishers are inspected annual, last inspection was conducted on 07/22/2021.

The facility currently has 14 residents with memory care needs. The facility provides structured activities to accommodate all residents. Potentially dangerous items, including sanitizers, are kept inaccessible to residents with dementia.

There are no security bars or weapons on the premises. Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

Advisory Notes with technical assistance were issued.

1. LPA did not observe printed copies of CDSS PINs made available to residents/ staff.



An exit interview was conducted, no deficiencies were cited during this visit, and a copy of this report was provided to administrator.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2