191800001-6-12-2023-28-AS-AGOZ-CSQVGP-20230612162551

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191800001
Report Date: 06/12/2023
Date Signed: 06/12/2023 04:25:56 PM

Document Has Been Signed on 06/12/2023 04:25 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
GREATER LA AC/SC, 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:	185	CENSUS: 144	DATE:	06/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
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	Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Diana Medina. LPA Gonzalez explained the purpose of today’s visit. The facility is licensed to operate for (100) ambulatory and (85) non-ambulatory elderly adults ages 60 and above. Facility has an approved hospice waiver for (8). Currently, the facility has (144) residents and (0) in hospice care. The facility consists of four separate buildings. Building #1 consists of 44 units, building #2 consists of 62 units, building #3 consists of 32 units and the memory care unit which is a two story building and contains a total of 21 units which all contain bathrooms. Buildings 1-3 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. Facility has a signal system that properly works from residents living units and bathrooms. The facility was observed to be in good repair. LPA toured the physical plant. LPA observed a water fountain on the facility premises which is properly fenced and in compliance with state and local building codes. LPA toured and inspected a random selection of resident rooms throughout Buildings 1-3 and memory care unit. All rooms that were inspected had the adequate beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. A total of 10 resident rooms were inspected which included bathrooms in each room. Restrooms were observed to be clean, and operational (w/grab bars and non-skid surface/mats in place). Hot water temperature tested between 111F - 120 F degrees. A comfortable temperature was maintained in the facility. (Evaluation Report continues LIC 809-C)*

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOLLENBECK PALMS	FACILITY NUMBER: 191800001
	VISIT DATE: 06/12/2023

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
26
27
28
29
30
31
32

LPA observed the facility to be properly furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately.

Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of the Medication Records Administration (MAR) was observed to be maintained in order and were completed accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed multiple First Aid Kits maintained in order and complete. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters, 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. Activity schedules observed posted throughout the facility.

LPA reviewed Resident 1-10 (R1-R10) facility files, and Staff 1-8 (S1-S8) personnel files and observed that all files were in order and complete and had the required completed documents and training. Resident files contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records. Staff files criminal background clearance and training, health clearance, food handling certificates, and 1st Aid/CPR training was observed.

No deficiencies during this inspection visit.

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

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2