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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603550
Report Date: 10/29/2024
Date Signed: 10/29/2024 11:54:04 AM

Document Has Been Signed on 10/29/2024 11:54 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WEST PARK SENIOR LIVINGFACILITY NUMBER:
198603550
ADMINISTRATOR/
DIRECTOR:		CRYSTENE CHARFACILITY TYPE:
740
ADDRESS:801 CYPRESS WAYTELEPHONE:
(909) 592-8844
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 200CENSUS: 110DATE:
10/29/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Administrator Crystene CharTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Tyler Reyes conducted a subsequent annual inspection visit. LPA met with Crystene Char and discussed the purpose of today’s visit.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator and (9) staff files. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights.

Resident Records-Incident Reports: LPA reviewed (11) Resident files. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Appraisal/Needs and Services Plan, Resident Rights were observed.

Resident Rights-Information: Resident rights are posted and included in Resident files.

Planned Activities: Facility has an activity calendar posted.

Disaster Preparedness: The facility has a Disaster Preparedness plan in place. Last Emergency Disaster Drill Completed on July 31st 2024.

Physical Plant & Environment Safety: LPA toured facility grounds. Multiple carbon monoxide detectors were observed in each floor (tested and operable). Fire extinguishers are located throughout the facility and on each floor. Hot water temperature measured within regulations. The hot water supply measured at the following temperatures: Room 103(105.4), Room 117(106.6), Room 209 (105.1), Room 303 (107), Room 405 (106.1), Room 521(111.5), Room 621 (109.4), and Room 711(113.5). Bathrooms had non-skid surfaces and grab bars.

**Continued LIC809-C**
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WEST PARK SENIOR LIVING
FACILITY NUMBER: 198603550
VISIT DATE: 10/29/2024
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Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. The facility also has emergency water supply and emergency paper goods. Posted menu observed. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining area has adequate seating.

Health Related Services/Incidental Medical Services: The medications are stored inside locked carts located in the medication room. The facility utilizes an electronic program to document residents’ medication administration. LPA reviewed medication for Resident #1 (R1-R5)

Exit interview conducted, a copy of this report was provided to Crystene Char.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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