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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205367
Report Date: 08/01/2024
Date Signed: 08/06/2024 04:11:27 PM

Document Has Been Signed on 08/06/2024 04:11 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:WESTCHESTER VILLAFACILITY NUMBER:
198205367
ADMINISTRATOR/
DIRECTOR:		EVANGELINE AGATEPFACILITY TYPE:
740
ADDRESS:220 W. MANCHESTER BLVD.TELEPHONE:
(310) 673-1093
CITY:INGLEWOODSTATE: CAZIP CODE:
90301
CAPACITY: 174CENSUS: 91DATE:
08/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:09 AM
MET WITH:Matthew Chinichian and Tawny GantTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Required - 1 Year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked.

LPA Bunker met with Licensee Matthew Chinichian and Administrator Tawny Gantn and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan and Infection Control Report. There are currently 91, residents and in placement. LPA Bunker verified current staff fingerprints that were cleared and associated with the facility. The facility's annual fees are current. The facility has a Dementia Program. The facility is licensed for three hospice care residents. The facility has sufficient staff available and competent to provide the services necessary to meet resident needs.

The following 12 Domains will be observed and reviewed: Infection Control, Operational Requirements, Physical Plant & Environmental Safety, Staffing, Personnel Records-Staff Training, Residents Rights-Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records-Incident Reports, Disaster Preparedness, and Residents with Special Health Needs. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

See continued LIC809-C page 2
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WESTCHESTER VILLA
FACILITY NUMBER: 198205367
VISIT DATE: 08/01/2024
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Continued LIC809-C page 3

LPA Bunker observed the facility’s infection control practices, screening protocols for residents and visitors, sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of Personal Protective Equipment (PPE) was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed. LPA observed staff wearing a face covering and social distancing.

Medications are locked and records are current. Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and clear of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, sprinklers, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 112 first floor and 115 degrees Fahrenheit on the second floor, fire extinguishers are fully charged, adequate linen supply, residents emergency call light is operable, the facility telephones are working, resident's bedroom windows have no sliding window lock with thumbscrew, all exit doors were in compliance, yard free of debris hazards, and trash cans were covered.

The last Fire/Emergency Drill was conducted on 07/22/2024.

Staff was given training on dependent adult and elder abuse reporting video.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WESTCHESTER VILLA
FACILITY NUMBER: 198205367
VISIT DATE: 08/01/2024
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Continued LIC809-C page 2

The above facility is a two-story commercial building. Administrator Tawny, LPA Bunker toured the facility which consisted of the following: The first-floor Lobby/receptionist area, business office/copy area, medication room, Administrator's office, record office, 24 bedrooms and bathrooms, emergency supply room, storage rooms, 3 living rooms, 2 dining rooms, kitchen, resident's private laundry room, commercial laundry room, activity room, recreation/activity director's office, men and women public restrooms, 2 employee's lounges, men and women employee's restrooms, beauty salon, linen room, housekeeping supply room, patios, shaded area, indoor/outdoor activity area, and gated security parking lot.

The Memory Care Unit (MCU) has 8 bedrooms and bathrooms, a living room/dining room Activity/TV area, and men's and women's public restrooms.

The second floor consisted of 52 resident bedrooms and bathrooms, a Doctor's office, a Home Health agency office, men's and women's public restrooms, men's and women employee's restrooms, a resident's private coin laundry room, TV room, library/living room, game room, storage rooms, and storage closets, upstairs patio area.

Licensee Matthew, Administrator Tawny, and LPA Bunker observed that 9 residents' bedrooms had the required furniture, a bed, one chair, a nightstand, adequate lighting, a closet, and drawer space. There was ample space to accommodate each resident comfortably. Documents are posted as mandated. Bedrooms contain the required furniture, and Bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, and comfort, including grab bars, and non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. See LIC809-C page 3
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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