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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191800001
Report Date: 04/13/2022
Date Signed: 04/13/2022 04:56:34 PM


Document Has Been Signed on 04/13/2022 04:56 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:HOLLENBECK PALMSFACILITY NUMBER:
191800001
ADMINISTRATOR:DIANA MEDINAFACILITY TYPE:
741
ADDRESS:573 S. BOYLE AVETELEPHONE:
(323) 263-6195
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY:171CENSUS: 131DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Diana MedinaTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Annual Required / Infection Control visit to the above facility. LPA was met by Administrator Diana Medina and the purpose of today’s visit was explained.

There are currently (123) residents in the facility. The facility is licensed to serve elderly residents age 60 and over, (171) total capacity with clearance for (32) non ambulatory.

LPA and Administrator Diana Medina toured the facility's physical plant inside and outside to ensure there are no health and safety hazards. The facility consists of three separate buildings. Building #1 consists of 44 units, building #2 consists of 62 units and building #3 consists of 32 units. The three separate buildings have rooms that contain kitchenettes, laundry rooms, and common areas for resident use. The facility has resident activity areas available in each building. The main building which is building #1 contains two activity areas, a gym, dining room, main dining room and a commercial kitchen. Resident bedrooms have the required furniture, bed linens, sufficient lighting and closet/drawer space to accommodate each resident comfortably. Private resident bathrooms in rooms were inspected. Restrooms were observed to be clean, and operational (w/grab bars and non-skid surface/mats in place). Hot water temperature tested between 116*F degrees. Hygiene supplies are provided. Required notifications and postings were observed throughout the facility in the different buildings located on bulletin boards and all included: Resident Personal rights, Facility sketch, Visitor policy, complaint procedures, menu and emergency disaster plan. Common areas and all indoor and outdoor passages were free of obstruction.

LPA toured the kitchen which appeared clean and the appliances and fixtures were functional. Kitchen observed to be within Title 22 regulations. The kitchen was observed for the ability to prepare and serve food.

SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOLLENBECK PALMS
FACILITY NUMBER: 191800001
VISIT DATE: 04/13/2022
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There was enough supply of perishable foods and enough nonperishable foods. Perishable food was stored in covered containers at the appropriate temperature. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. The facility has central air and heating accommodations. The air temperature was cool and comfortable throughout the facility at the time of visit. Smoke detectors and carbon monoxide detectors were working properly, and fire extinguishers were fully charged. There are no security bars or weapons on the premises. Facility fountain is secured by a metal gate. Facility has a signal system that properly works from residents living units. The facility was observed to be in good repair.

The following was observed/inspected:


  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms and hallways throughout the facility.
  • Staff conducted a routine symptom screening of LPA at the time of entrance and have a sign-in policy as required per COVID-19 procedures.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Residents are able to use their private accommodations as isolation rooms as all resident rooms are private and facility also has a designated COVID-19 isolation room that is available to be used for residents that have a shared room, such as couples, if a COVID-19 positive case should arise.
  • Per Administrator Medina, all Residents and staff are fully vaccinated.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Residents were socially distanced according to local public health guidelines.
  • Residents were observed wearing masks.
  • Facility has an adequate amount of PPE and facility has enough PPE for 30 months.
  • Restrooms were observed to have sufficient soap, paper towels, hand sanitizer and signs promoting proper hand washing etiquette.
  • Residents temperature is checked and logged once a day.
  • Staff temperatures are checked and logged twice a day, upon beginning of shift and then again at the end of their shift.

According to the California Code of Regulations, LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator Diana Medina and copy of report provided.

SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2