195850520-12-6-2024-29-AS-TBYE-DBPTKV-20241206134834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850520
Report Date: 12/06/2024
Date Signed: 12/06/2024 01:48:45 PM

Document Has Been Signed on 12/06/2024 01:48 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FINE GOLD MANOR		FACILITY NUMBER:	195850520
ADMINISTRATOR/ DIRECTOR:	CRISTINA GOMEZ		FACILITY TYPE:	740
ADDRESS:	10537 MAGNOLIA BLVD.		TELEPHONE:	(818) 761-5777
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91601
CAPACITY: 100		CENSUS: 59	DATE:	12/06/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Christina Gomez		TIME VISIT/ INSPECTION COMPLETED:	02:00 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) Trevor Byrne conducted a pre-licensing visit to the above noted facility. The LPA met with Administrator, Christina Gomez. This is a change of ownership application. A Hospice Waiver has been requested. The facility is three (3) stories. At 09:10 AM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for one-hundred (100) non-ambulatory and ambulatory residents. The facility has sixty-one (61) private resident bedrooms, and two (2) shared room(s), Room numbers nine (9) and fifty (50). All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. Rooms # twenty-six (26) and sixty-three (63) were observed to contain ripped screens. There are four (4) bathrooms in the hallway. Each resident bedroom is equipped with an attached private bathroom. The resident bathrooms have a shower with non-skid materials. All toilets and showers have appropriately secured grab bars. The hot water temperature was tested in the bathrooms and the kitchen. The kitchen water was measured to be 127.4 degrees Fahrenheit, LPA observed warning signs near the kitchen sinks. Continued on LIC 809C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FINE GOLD MANOR	FACILITY NUMBER: 195850520
	VISIT DATE: 12/06/2024

NARRATIVE

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Resident and staff records are stored securely in the Administrator’s office. Medications are centrally stored in a locked medication room on the first floor of the facility. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. First aid kits are located throughout the facility.

Kitchen knives are stored securely in the kitchen. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at thirty-two degrees Fahrenheit (32*F). The supply of nonperishable and perishable food is adequate. At 09:16 AM LPA observed the facility refrigerator to contain moldy strawberries. At 09:34 AM LPA observed the facility emergency food supply to contain eleven (11) cans of expired peaches. There are no pesticides, poisons, or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in locked closets located throughout the facility’s hallway. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and activity supplies in the facility’s activity rooms. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight were made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There are no fireplaces located at the facility. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. There are pull stations throughout the facility. The smoke detector and carbon monoxide detectors were tested at 11:56 AM and functioned properly during the time of visit. There are ten (10) fire extinguishers throughout the facility. All are fully charged and do not exceed the expiration date. Continued on LIC 809C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FINE GOLD MANOR	FACILITY NUMBER: 195850520
	VISIT DATE: 12/06/2024

NARRATIVE

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Hot water was tested in each bathroom, which included the resident bathrooms and any common bathrooms, in addition to the kitchen; the hot water ranged between 97.3 and 131.7 degrees Fahrenheit which is outside of the range allowed by regulations. The laundry area is located in the hallway on the first floor of the facility. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored by residents in their own rooms. Extra incontinence supplies are stored in the facility basement. There are functioning telephones on the premises. The emergency exiting plans/sketch are posted throughout the facility’s hallways. The emergency telephone numbers are posted in the lobby next to the facility elevator along with other required postings.

The exterior passageways were clean and clear of any obstructions. There are covered balconies attached to each resident room. There is a patio located in the center of the facility with adequate seating for resident use. The garage gate is moved automatically. There are not any bodies of water on the premises at the present time. The garage is accessible from the facility.

The Component Three (COMP III) presentation was conducted with the facility Administrator Christina Gomez at the time of the visit.

The following items, and a follow-up pre-licensing inspection, must be corrected prior to licensure. Submit proof of corrections, along with a copy of this report, to LPA Byrne so that your application may be completed.

87303(e)(2) - (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 degree C) and not more than 120 degree F (49 degree C).

87303(c) - (c) All window screens shall be clean and maintained in good repair.

87555(b)(8) - (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC809 (FAS) - (06/04)

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