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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191800001
Report Date: 04/04/2024
Date Signed: 04/04/2024 03:47:17 PM


Document Has Been Signed on 04/04/2024 03:47 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 PALMSFACILITY NUMBER:
191800001
ADMINISTRATOR:DIANA MEDINAFACILITY TYPE:
741
ADDRESS:573 S. BOYLE AVETELEPHONE:
(323) 263-6195
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY:185CENSUS: 162DATE:
04/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Morris Shockley - LicenseeTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Erik Zaragoza and Daniel Konishi conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Morris Shockley, President and CEO of Hollenbeck Palms, and was granted entrance. Administrator Diana Medina arrived shortly thereafter. There are one hundred and sixty-two (162) residents currently living in the facility.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.


Physical Plant/Environment Safety:

· The facility consists of four separate buildings. It is licensed for a capacity of one hundred (100) ambulatory and eighty five (85) non-ambulatory residents, with a hospice waiver approved for eight (8) residents. LPAs toured building 1 which has a total of forty-five (45) resident bedrooms, and building #2 which has a total of sixty-two (62) resident bedrooms. Buildings 1-2 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.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOLLENBECK PALMS
FACILITY NUMBER: 191800001
VISIT DATE: 04/04/2024
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Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for a capacity of one hundred (100) ambulatory and eighty five (85) non-ambulatory residents, with a hospice waiver approved for eight (8) residents.


· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of one hundred and sixty-seven (167) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Eight (8) staff files were reviewed for criminal background clearance and training.



Resident Rights/Information:

· Physician orders were reviewed for eight (8) resident files.

· Medications were also reviewed for eight (8) residents.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 04/04/2024
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Resident Records/Incident Reports:

· Eight (8) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.


Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.


Incident Medical and Dental:

· All residents have an Appraisal/Needs and Services Plan on file.

· Staff training was on file.

Due to time constraints, LPAs were not able to complete the annual inspection during today's visit. LPAs will return at a later date in order to complete the inspection.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
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