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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002676
Report Date: 09/23/2021
Date Signed: 09/23/2021 03:36:36 PM

Document Has Been Signed on 09/23/2021 03:36 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:WESTSIDE ASSISTED LIVINGFACILITY NUMBER:
455002676
ADMINISTRATOR:ENEIX, AUDRAFACILITY TYPE:
740
ADDRESS:915 HALLMARK DRTELEPHONE:
(530) 605-4041
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY: 6CENSUS: 6DATE:
09/23/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Gurmeel and Reema Singh-AdminsitratorsTIME COMPLETED:
03:30 PM
NARRATIVE
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On 09/23//2021, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced Case Management Health and Safety visit as directed by the department. LPA met with Administrator Licensee Gurmeel Singh and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical masks. Additionally, LPA was screened by staff at the front door

LPA toured the facility inside and out including but not limited to facility dining areas, outside areas, staff break rooms, kitchen area. LPA observed that the facility has had some renovations done. The following renovations has been completed included; Bathroom remodeled, added counters, cabinets in the kitchen area, new flooring and painting throughout facility, a wall that has been removed, bedrooms and bathrooms has been added. LPA asked Licensee if there was a permit application on the changes to the facility. Licensee reported that “my architect is in the process of getting that completed.” LPA explained to Licensee that when there are any kind of alternations to the facility, licensee needs to report such changes and a permit completed prior to the remodel, which also needs to be approved as well as a fire inspection completed. Licensee reported that he was not aware of having to notify LPA but will from now on. LPA asked about residents in care and where have they been throughout the remodeling. Licensee reported that all residents in care have been removed from the facility in process of remodeling.

continue on 809-C
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: WESTSIDE ASSISTED LIVING
FACILITY NUMBER: 455002676
VISIT DATE: 09/23/2021
NARRATIVE
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LPA requested to see documentation that residents and families have been notified of the movements. Licensee reported that they never provided any documentation regarding the moves and that they have been in contact with all residents and their families verbally. LPA explained to Licensee that LPA will be citing Licensee regarding the unreported alternations in the facility, reporting requirements to LPA on changes, no fire clearance on renovations, and illegal evictions. Licensee understood and reported that he will contact LPA with any changes to the facility from here on out.

Deficiencies are cited on LIC 809D.

Exit interview conducted and a copy of report along with appeal rights were given.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/23/2021 03:36 PM - It Cannot Be Edited


Created By: Misty Valencia On 09/23/2021 at 02:30 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WESTSIDE ASSISTED LIVING
FACILITY NUMBER: 455002676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2021
Section Cited
CCR
87305(a)

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Alterations to Existing Building or New Facilities (a)Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidence by:
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Licensee agrees to submit a floor plan to the licensing agency that indicates the physical floor plan changes. Licensee shall submit the floor plan to the licensing agency by 10/01/2021
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The licensee has made some alterations to the facility and did not seek approval from the licensing agency or the fire marshal, as required. This poses an as a otential health and safety risk to residents in care.
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Type B
10/01/2021
Section Cited
CCR87202

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All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...or the State Fire Marshal. This requirement is not met as evidenced by:
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Licensee agrees to get Facility renovations cleared by the fire Marshal and provide clearance to LPA by 10/01/2021
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Based on LPA observation, licensee did not maintain a fire clearance to the alternations made at the facillity. This poses an as a otential health and safety risk to residents in care
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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:Maribeth Senty
LICENSING EVALUATOR NAME:Misty Valencia
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2021


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/23/2021 03:36 PM - It Cannot Be Edited


Created By: Misty Valencia On 09/23/2021 at 02:33 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WESTSIDE ASSISTED LIVING
FACILITY NUMBER: 455002676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2021
Section Cited
CCR
87224(a)

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Eviction Procedures. (a) The licensee may evict a resident for one or more of the reasons listed ... This requirement was not met as evidenced by:
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Licensee agrees to submit a statement of understanding of this regulation to LPA by 10/01/2021
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all residents were moved during facility alterations and not given an approriate 60 day notice. This posed a potential risk to resident's personal rights.
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Type B
10/01/2021
Section Cited
CCR87211(a)(1)

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Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible for the...
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Licensee stated that a written plan will be submitted to Licensing stating how facility can ensure a written report is submitted to Licensing and Responsible Party of residents in the future by 10/01/2021
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This requirement has not been met as evidenced that the licensee did not sure that licensee reported alterations done to the facility This is a potential health, safety or personal rights risk to the residents in care.
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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:Maribeth Senty
LICENSING EVALUATOR NAME:Misty Valencia
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2021


LIC809 (FAS) - (06/04)
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