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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191800001
Report Date: 11/29/2022
Date Signed: 12/28/2022 04:46:06 PM


Document Has Been Signed on 12/28/2022 04:46 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:185CENSUS: DATE:
11/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Diana Medina, AdministratorTIME COMPLETED:
04:15 PM
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***This report was originally had written by LPA Calderon on 11/29/22 and on 12/28/22 typed on FAS***

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced case management visit due to an incident reported to Licensing on 11/02/2022. LPA met with the Administrator, Diana Medina, and explained the purpose of the visit.

The incident report states, Resident #1 (R1) lost balance and fell from stair case on the exterior Magnolia Court corridor, from the Bistro building. Per the Administrator, Diana Medina R1 was an independent resident, did not require any assistance, fully ambulatory. Based on the physician's report, R1 is able to leave the facility unassisted and does not have Dementia or any cognitive impairment.

LPA and Medina toured the outside of Palm Plaza courtyard and Magnoila Court Building (M.C.B), is where R1 fell, on the extgerior staircase of building. LPA interviewed Diana Medina and interviewed R1 in the SNIF side of the facility. LPA gathered and reviewed Physician Report, Facesheet, Preplacement Apprasal, Hospital Report, Medication Records, Radiology Result Report, Orthopedic Notes, Physical and Occupational records.

Based on record review R1 was discharged from the hospital on 11/08/22 and admitted to the SNIF for recovery.

Based on the information gathered, there is no signs of neglect or lack of supervision found. No deficiency was issued.

An exit interview was Administrator Diana Medina and a copy of this report was provided to the Administrator.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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