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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603259
Report Date: 02/02/2023
Date Signed: 02/02/2023 02:33:47 PM

Document Has Been Signed on 02/02/2023 02:33 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, 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:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Zaruhi (Sara) Tekeian - Management staffTIME COMPLETED:
02:46 PM
NARRATIVE
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On 2/02/23, at 10:30AM, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced required Annual visit with a primary focus on infection control. LPA was met by Zaruhi (Sara) Tekeian, House Manager (HM1), House Manager and LPA spoke with Hasmik Tekeian, Co-Administrator (CA1), via phone and the purpose of today’s visit was explained.

There are currently (2) residents in the facility. One (1) resident(s) are ambulatory and one (1) are non-ambulatory. The facility is a double-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 of four (4) bedrooms (one (1) in loft), (2) full bathrooms, kitchen, living / dining room, shaded front yard, laundry room, loft and no garage.

LPA and HM1 toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were clean and operational, yet outside of Title 22 regulations. The water temperature measured at 122.9 F in the kitchen and 124.5 F in bathroom 2. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, as of 12/07/22, smoke detectors and Carbon Monoxide were operable.



see LIC809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SWEETZER SENIOR GARDEN
FACILITY NUMBER: 198603259
VISIT DATE: 02/02/2023
NARRATIVE
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (located in common areas and restrooms). LPA observed staff were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility does not have a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PINs) for any updates relating to COVID-19 guidance.

During today’s visit there were three (3) deficiencies observed, see LIC809-D. Technical assistance notes were provided, see LIC9102.

Exit interview held. A copy of the report, deficiencies, civil penalties, and appeal rights were provided to Zaruhi (Sara) Tekeian.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/02/2023 02:33 PM - It Cannot Be Edited


Created By: Mario Leon On 02/02/2023 at 01:31 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: 02/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Licensing Program Analyst's observation, the licensee did not comply with the section cited above in which faucets were providing temperatures above 120 F (122.9 F in kitchen, 124.5 F in bathroom 2) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2023
Plan of Correction
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House manager, Zaruhi (Sara) Tekeian, will provide email (mario.leon@dss.ca.gov), video evidence of the water temperature being taken within Title 22 regulations, as listed above, on or prior to the POC due date which is 02/06/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/02/2023 02:33 PM - It Cannot Be Edited


Created By: Mario Leon On 02/02/2023 at 01:31 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: 02/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in having the centrally stored medication properly stored inaccessible in the locked drawers present within the living room next to the kitchen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2023
Plan of Correction
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Administrator(s)/House Manager will conduct staff training regarding centrally stored medication properly locked and inaccessible to clients and/or fellow staff members. In addition, the facility will produce a folder specifically for a sign-out and sign-in sheet to maintain all safety measures related to the centrally stored medication remaining locked and inaccessible. All proofs shall be submitted to mario.leon@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/02/2023 02:33 PM - It Cannot Be Edited


Created By: Mario Leon On 02/02/2023 at 01:32 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: 02/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355


This requirement is not met as evidenced by:
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
Deficient Practice Statement
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Based on staff record review, the licensee did not comply with the section cited above in two counts (S1, S2) while LPA was on-site, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2023
Plan of Correction
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Administrator Diana Tekeian will obtain S1 and S2 personnel ID and will enter Guardian access (see https://guardian.dss.ca.gov), upon which Mrs. Diana will request the transfer of S1, S2 and all other possible caregivers or administrators. Mrs. Diana will inform LPA through email, including a screenshot of her updated LIC500 via Guardian. If that is impossible, Administrator will provide proof of certified mail of transfer request having been sent to 1000 Corporate Center Drive, Monterey Park, CA 90745 prior to POC due date, or will personally stand in as required staff for the care of clients who are currently present.
All unassociated staff will remain off-site until deficiencies have been cleared. Document agreeing to previous statement will be submitted to mario.leon@dss.ca.gov prior to POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023


LIC809 (FAS) - (06/04)
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