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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606651
Report Date: 06/07/2022
Date Signed: 06/07/2022 03:02:29 PM


Document Has Been Signed on 06/07/2022 03:02 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:LAKEWOOD GARDENSFACILITY NUMBER:
197606651
ADMINISTRATOR:SHOLOM YOSEF GOLDMANFACILITY TYPE:
740
ADDRESS:12055 S. LAKEWOOD BLVD.TELEPHONE:
(562) 869-4038
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY:150CENSUS: 64DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Joe Goldman - AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Administrator Joe Goldman and explained the purpose of today's visit. The facility is licensed to serve 150 non-ambulatory residents 60 years and above. The facility has a dementia special program, delayed egress system and hospice waiver granted for 27 residents. The facility is located in a commercial area. A tour of the single-story facility included: reception/screening area, activity room, 1 common restroom, dining room, kitchen, 6 resident rooms and bathrooms, 2 outside patios, medication room, and storage room.

LPA and Joe Goldman toured the facility and the following was observed: the 2 outside patios are clean and there are shaded seating areas for the residents. Passageways and exits are free of obstruction. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in the 6 residents’ bathrooms and 1 common restroom and measured between at 109 and 113 degrees F, which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed in each room and throughout the facility and are properly operating. There are multiple carbon monoxides throughout the facility and are properly operating. There are multiple fire extinguishers throughout the facility, which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are kept in the kitchen and are inaccessible to the residents. Cleaning supplies and toxins are kept in a locked storage. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. First Aid kit was fully stocked with current manual and it is kept in the medication room. Residents medication are centrally stored in the medication room. Residents and staff files are centrally stored in the administrator’s office. (CONTINUED TO LIC 809C)
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LAKEWOOD GARDENS
FACILITY NUMBER: 197606651
VISIT DATE: 06/07/2022
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LPA reviewed medication for six residents and observed that medications are documented properly and given as prescribed. LPA reviewed files for six residents and found no issues. LPA reviewed files for four staff and found no issues. LPA observed administrator certificate for Joe Goldman– 6001171740 with an expiration date of 05/03/2023.

Facility is following COVID 19 recommendations regarding screening visitors, staff, and residents. Signs are posted throughout the facility, and hand-washing signs were observed in bathroom. Sufficient hand soap, hand sanitizer, and paper towels were observed. Supply of 30-day Personal Protective Equipment (PPE) was observed in the storage room.



Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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