197602348-9-27-2024-31-AS-AAEA-D9HUTE-20240927155150

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602348
Report Date: 09/27/2024
Date Signed: 09/27/2024 03:52:19 PM

Document Has Been Signed on 09/27/2024 03:52 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 S.RO, 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:	09/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Licensee, Aurelio S. Trillana and Administrator, Maria L. Tiopianco-Trillana		TIME COMPLETED:	04:00 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) Antonia Alvizar-Ettima conducted an unannounced One (1) Required year inspection at this facility. LPA met with Licensee, Administrator and explained the reason for the visit. A tour of the physical plant was conducted at 10:30a.m. and the following were noted: The facility has one main entrance being used. Required posting are observed to be complete and current and displayed properly. The facility has an approved mitigation and infection control plan on file. The facility is a single story building and has four (4) bedrooms and three (3) bathrooms in a residential street. 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. All smoke alarms were tested and function properly. The fire extinguisher was last purchased on 05/17/2024. Dual smoke and carbon monoxide are hardwired and interconnected and was tested and functions properly. Fire extinguishers are in the living room, kitchen, office area and observed to be full date of purchased 05/17/2024. Disaster drill was last conducted on 08/23/2024. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: 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 73°F.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ST. ANNE'S GOLDEN YEARS HOME	FACILITY NUMBER: 197602348
	VISIT DATE: 09/27/2024

NARRATIVE

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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. The kitchen appeared clean and the appliances and fixtures functional. Knives and sharps are observed to be kept in the kitchen cabinet locked and inaccessible to residents. Resident rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lit. Residents have sufficient amounts of personal hygiene product which is provided by the licensee. Bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet and shower. The hot water temperature measured at a range of 112.3°F to 116.0°F. Towels and washcloths are not shared. There is enough clean linen available in stock in the linen cabinet located in the hallway. Medications: LPA observed medication in the kitchen locked cabinet and inaccessible to residents. First aid kit is observed to be with complete tools and supplies. Garage detached to the facility and used to storage for supplies, tools and extra frozen food. Laundry room is located at the side of the facility with no access from inside. Laundry room was observed to be locked and inaccessible to residents. Laundry detergent, cleaning agents and other toxins are observed to be locked and secured in the locked laundry room.

Backyard of the facility has outdoor furniture, with a covered shaded area for residents. The front and backyard passageways were clear of any obstruction. There is no body of water at the facility.

Staff records were reviewed. Staff present had criminal record clearances and associated to this facility.
Staff records appear to be complete and current.

Resident records were also reviewed and appeared to be complete and current.

There is no health and safety issue observed during this visit. Exit interview conducted. A copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC809 (FAS) - (06/04)

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