197602348-12-22-2022-31-AS-JGTN-CMD27V-20221222160921

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602348
Report Date: 09/16/2022
Date Signed: 12/22/2022 04:09:28 PM

Document Has Been Signed on 12/22/2022 04:09 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ST. ANNE'S GOLDEN YEARS HOME		FACILITY NUMBER:	197602348
ADMINISTRATOR:	TIOPIANCO, MARIA		FACILITY TYPE:	740
ADDRESS:	5153 EAGLEROCK BOULVARD		TELEPHONE:	(323) 550-1170
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90041
CAPACITY:	6	CENSUS: 5	DATE:	09/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:02 PM
MET WITH:	Maria Tiopianco - Administrator		TIME COMPLETED:	03:15 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) Gary Tan conducted an unannounced One (1) year Required Infection Control visit at this facility. LPA met with administrator Maria Tiopianco and explained the purpose of this visit. A tour of the physical plant was conducted at 12:15 PM and the following was observed: The facility has one main entrance being used, required Covid-19 prevention signage (hand washing, coughing etiquette and physical distancing) are posted on the door. The PPE screening station is located in the living room area on a table equipped with sufficient PPE readily accessible, a thermometer, hand sanitizer, gloves, mask and sign in sheet at the time of visit. Visitors are required to wear mask. The facility has an approved mitigation and infection control plan on file. The facility is a single storey building and has four (4) bedrooms and three (3) bathrooms. One (1) bedroom is designated for staff use. The facility is Fire cleared for four (4) non-ambulatory residents, one (1) of which maybe bedridden. Hospice waiver for three (3) residents. Living and dining room furniture were checked. The living room is neat and clean along with the dining room. Furniture were observed to be in good repair and excellent condition. The facility maintains a comfortable temperature at 75°F. The smoke alarms are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector installed at the facility. Fire extinguisher is located at the kitchen and observed to be full and current. (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ST. ANNE'S GOLDEN YEARS HOME	FACILITY NUMBER: 197602348
	VISIT DATE: 09/16/2022

NARRATIVE

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(continued from LIC 809)

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in the kitchen drawer and inaccessible to residents. Laundry room is located at the side of the house and observed to be locked and inaccessible to residents. Laundry detergent, cleaning solutions and other toxins are observed to be locked and secured in the locked laundry room.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

The Bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured at a range of 105.1°F to 106.8°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPA observed that the medication are kept in the kitchen cabinet and observed to be locked and inaccessible to residents. There was a complete first aid kit located in the kitchen

Garage: The garage is currently being used as a tool and supplies storage.

The Backyard had a covered shaded area for clients with outdoor furniture. There is no body of water at the facility.

Exit interview conducted. Copy of this report issued

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

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