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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191800001
Report Date: 04/16/2024
Date Signed: 04/16/2024 02:39:59 PM

Document Has Been Signed on 04/16/2024 02:39 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/
DIRECTOR:		DIANA MEDINAFACILITY TYPE:
741
ADDRESS:573 S. BOYLE AVETELEPHONE:
(323) 263-6195
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY: 185CENSUS: 162DATE:
04/16/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:32 AM
MET WITH:Diana Medina - Administrator TIME VISIT/
INSPECTION COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analysts (LPA) Erik Zaragoza conducted a subsequent unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools in order to complete the annual inspection. LPA explained the purpose of the visit Diana Medina, administrator for the facility, and was granted entrance. 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.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed.


· Infection control plan is on file.
Physical Plant/Environment Safety:

· The facility consists of four separate buildings all located on a campus. 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. LPA toured building #1 which has a total of forty-five (45) resident bedrooms, building #2 which has sixty-two (62) bedrooms, Building #3 which has a total of sixty-five (65) bedrooms, and Building #4 which has thirty-three (33) bedrooms and also serves as the facility’s memory care unit. 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. Building #4 contains an activity room for residents. The facility has a signal system that properly works from residents living units and bathrooms. The facility was observed to be in good repair.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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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Document Has Been Signed on 04/16/2024 02:39 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 04/16/2024 at 12:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOLLENBECK PALMS
FACILITY NUMBER: 191800001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 4 out of 28 residents, because 4 of the resident rooms had a hot water temperature reading under 105 Degrees F, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2024
Plan of Correction
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Administrator is to ensure that the hot water temperature in all resident bathrooms will remain within the required 105 - 120 Degree F range. Administrator is to keep a log of the hot water temperatures for rooms #111, 115, and 122 in Rose Terrace, and room #115 in Hensel Memory Center and email LPA the water temperature logs with readings that fall within the required range by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


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: 04/16/2024
NARRATIVE
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·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. A water fountain on the facility premises is properly fenced and in compliance with state and local building codes. The facility has multiple fully charged fire extinguishers located throughout all four (4) building of the campus. There were no sharp objects that were left accessible to residents.
· Water temperature readings in four (4) out of twenty-eight (28) resident rooms reviewed fell below the required range of 105 - 120 degrees Fahrenheit.
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.


· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Resident Rights/Information:

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

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

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.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
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: 04/16/2024
NARRATIVE
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 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.

Disaster Preparedness:

· Emergency and Disaster Plan was publicly posted and found within the facility.


· An emergency and disaster drill was last conducted on 3/19/2024.

Planned Activities:

· Sufficient Space is provided to accommodate both indoor and outdoor activities.


· Sufficient equipment and supplies are provided to meet the requirements of the activity program.
Residents with Special Health Care Needs:

· The facility has a non-ambulatory fire clearance for each room that will be used to accommodate residents with a dementia diagnosis.


· Staff that provide direct care to residents with dementia receive training related to dementia care.
· There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit are documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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