197606845-2-22-2023-29-AS-EPEI-CPAU63-20230222141739

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606845
Report Date: 02/22/2023
Date Signed: 02/22/2023 02:18:08 PM

Document Has Been Signed on 02/22/2023 02:18 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FINE GOLD MANOR RETIREMENT		FACILITY NUMBER:	197606845
ADMINISTRATOR:	CRISTINA GOMEZ		FACILITY TYPE:	740
ADDRESS:	10537 MAGNOLIA BLVD.		TELEPHONE:	(818) 761-5777
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91601
CAPACITY:	100	CENSUS: 60	DATE:	02/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:18 PM
MET WITH:	Cristina Gomez, Administrator		TIME COMPLETED:	02:30 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) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 12:18 p.m., the LPA was greeted and screened by staff. The LPA met with the Administrator and explained the reason for the visit. This annual had a specific emphasis on infection control practices and procedures. At 12:43 p.m., the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards. KITCHEN: At 12:44 p.m., the LPA observed the kitchen/dining area. Knives are stored in the locked kitchen cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed emergency food and water located in a locked storage room near the kitchen area. At 12:44 p.m., the hot water measured at 106.1-degree Fahrenheit. BEDROOMS: The LPA observed multiple resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid surfaces. At 1:08 p.m., hot water was measured at multiple restrooms and was found to be within the range of 105 and 120-degree Fahrenheit. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. At 12:52 p.m., the LPA observed residents participating in a game of bingo. The LPA observed the fire extinguishers on both floors to be fully charged and last serviced on 01/18/2023. Signs are posted throughout facility to promote handwashing, cough/sneeze etiquette, and physical distancing. Fire alarm/sprinkler system was observed and was last tested on 08/08/2022. The LPA observed cameras installed in the hallways and common areas. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FINE GOLD MANOR RETIREMENT	FACILITY NUMBER: 197606845
	VISIT DATE: 02/22/2023

NARRATIVE

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OUTDOOR SPACE: The LPA observed the courtyard, which has a covered outdoor area for resident use. There are multiple emergency exits located throughout the facility on both floors. Passageways were free and clear from obstruction. The facility has an underground parking garage. Inside the garage there is additional storage areas that are inaccessible to residents. OTHER: Medications and first aid kits are located in a locked medication room. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the janitor room near the kitchen. The laundry units are located inside the locked laundry room. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed 30 days of Personal Protection Equipment (PPE). The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were observed at this time. Exit interview conducted. A copy of the report was provided via email and print.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC809 (FAS) - (06/04)

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