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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603259
Report Date: 02/03/2022
Date Signed: 02/11/2022 09:35:23 AM

Document Has Been Signed on 02/11/2022 09:35 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
MONTEREY PARK, CA 91754
FACILITY NAME:SWEETZER SENIOR GARDENFACILITY NUMBER:
198603259
ADMINISTRATOR:TEKEIAN, DIANAFACILITY TYPE:
740
ADDRESS:8309 WEST 3RD STREETTELEPHONE:
(323) 639-5934
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY: 6CENSUS: 2DATE:
02/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Sara Tekeian, House ManagerTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ana Soto and Jeremiah Randle conducted an unannounced Annual required and infection control visit to the above facility. LPA's were met by Sara, House Manager and spoke with DianaTekeian, administrator via phone and the purpose of today’s visit was explained.

There are currently (2) residents in the facility. (0) residents are ambulatory and (2) are non-ambulatory. The facility is a single story structure with a ramp and front porch located in a residential / commercial neighborhood. The facility is located in the back of the building near the alley. It consists (3) bedrooms, (2) full bathrooms, shaded front yard, laundry room and no garage.

LPA's and Sara toured the entire facility inside and out. Documents are posted as mandated. See something say something and oxygen in use posters were not posted in the facility. Bedrooms 1 & 2 are occupied by residents and contain the mandated furniture. Bedroom 3 is vacant . The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector are inter connected and were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Residents Medications did not have a centrally stored list and staff & resident files were not available for inspection. Ample supply of perishable and nonperishable food, hot water temperature is 120 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 1 fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged and temperature checked, sanitizer/soap in the staff bathroom. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) and missing isolation postings and other posting were posted. throughout the facility. The residents temperature's are checked and logged once a day. PPE's were not available for inspection. Isolation cart was missing.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies, therefore citations were issued.

An exit interview conducted with Sara Tekeian, Administrator and copy of report provided via email.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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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Document Has Been Signed on 02/11/2022 09:35 AM - It Cannot Be Edited


Created By: Ana Soto On 02/03/2022 at 12:16 PM
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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SWEETZER SENIOR GARDEN
FACILITY NUMBER: 198603259

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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87618(b)(B) No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This was not met as evidence by based on no posting in the facility. This is a health safety risk for residents.
POC Due Date: 02/17/2022
Plan of Correction
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Administrator will take picture of poster and send by email, fax, or text to LPA Soto by POC due
Section Cited
Deficient Practice Statement
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87468(c)(2)(A)Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility. PUB 475 may be accesse, downloaded, and printed from the www.ccld.ca.gov website.This was not met as evidence by based on no posting in the facility. This is a health safety risk for residents.
POC Due Date: 02/17/2022
Plan of Correction
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Administrator will take picture of poster and send by email, fax, or text to LPA Soto by POC due
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:Janae Hammond
LICENSING EVALUATOR NAME:Ana Soto
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/11/2022 09:35 AM - It Cannot Be Edited


Created By: Ana Soto On 02/03/2022 at 12:34 PM
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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SWEETZER SENIOR GARDEN
FACILITY NUMBER: 198603259

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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87465(a)(7)When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This was not met as evidence by based on no medication list. This is a health safety risk for residents.
POC Due Date: 02/17/2022
Plan of Correction
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Administrator will take picture of list and send by email, fax, or text to LPA Soto by POC due
Section Cited
Deficient Practice Statement
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87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information.This was not met as evidence by based on no staff/residents file available for inpection. This is a health safety risk for residents.
POC Due Date: 02/17/2022
Plan of Correction
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Administrator will contact LPA and set up appointment to take file to office for inspection and by POC due
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:Janae Hammond
LICENSING EVALUATOR NAME:Ana Soto
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022


LIC809 (FAS) - (06/04)
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