191800001-4-13-2022-28-AS-AGOZ-CDFW42-20220413165648

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191800001
Report Date: 04/13/2022
Date Signed: 04/13/2022 04:56:53 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 PALMS		FACILITY NUMBER:	191800001
ADMINISTRATOR:	DIANA MEDINA		FACILITY TYPE:	741
ADDRESS:	573 S. BOYLE AVE		TELEPHONE:	(323) 263-6195
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90033
CAPACITY:	171	CENSUS: 131	DATE:	04/13/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Diana Medina		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	LPA Alma Gonzalez conducted an announced visit to the facility for the purpose of a Case Management Visit. LPA met with Administrator Diana Medina. The facility is requesting an increase in capacity from 171 to 185 residents. The fire safety inspection was granted by Inspector, Alejandro Medina, of the Los Angeles County Fire Department on 3/20/22. The fire clearance was granted to serve 85 non-ambulatory residents. Memory Care building approved for Delayed egress. There are a total of 5 doors with the delayed egress system in the memory care unit. During today's visit, LPA Administrator Diana Medina and Vice President Patricia Murphy toured the facility's memory care unit. LPA toured bedrooms, bathrooms, activity room, dining area, patio area, and medication room. The memory care unit has 1 main entrance and 3 additional doors that lead to the outside, with delayed egress system. The doors can be accessed by pushing the doors open, which will activate the alarm, or by entering a code on the electronic key code pad and or using a key to deactivate the alarm. The memory care unit consists of: Building is two stories and contains a total of 21 units which all contain bathrooms. There are 5 shared units and 4 single units on the first floor and 7 shared units and 5 single units on the second floor. Each floor has a dining/ living room area, activity room, storage rooms, laundry room and a kitchen. There is a spa/ salon located on the first floor and the medication room is on the first floor. All bedrooms have new vinyl flooring, and freshly painted walls. All units have emergency pull cords in the bedroom and bathrooms, which were tested and working. All bathrooms have new tile, fresh paint, and new fixtures. All bedrooms have new thermostats and the common areas are cooled by a centralized cooling system. LPA observed that bedrooms and bathrooms meet Title 22 Regulations. Toilets and sinks worked properly. Grab-bars in bathrooms were secure. All medications will be stored in the medication room which will be locked at all times. Delayed egress system was tested and working. Water temperature in resident's bathrooms measured between 116 * F.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (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)

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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, 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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The patio to the memory care unit is enclosed. There are two doors that can be opened by pushing the door open, which will activate the alarm, or by entering a code using a key to deactivate the alarm. Delayed egress system was tested and is working. All walkways around the memory care unit were clear of hazards. There are no bodies of water.

There were no deficiencies cited on today's visit.

Exit interview and copy of report provided to Administrator Diana Medina.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (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)

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