197606845-3-16-2022-29-AS-EPEI-CCKSSU-20220316140831

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606845
Report Date: 03/16/2022
Date Signed: 03/16/2022 02:09:28 PM

Document Has Been Signed on 03/16/2022 02:09 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. #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: 63	DATE:	03/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Cristina Gomez, Administrator		TIME COMPLETED:	02:15 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	At 12:00 p.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff. At 12:04 p.m., 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 12:27 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 and facility is in compliance with Title 22 Regulations. COMMON AREAS: LPA observed common area to be relatively clean and properly furnished. At 2:28 p.m., LPA observed the media room which has puzzles and games for resident use. LPA observed the fire extinguishers on both floors to be fully charged and last serviced on 04/30/2021. Flashlights were observed throughout the facility. 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 11/06/2020 with an expiration date of 03/31/2023. LPA observed cameras installed in the hallways and common areas. KITCHEN: At 12:31 p.m., LPA observed the kitchen/dining area. Knives are stored in a locked kitchen cabinet inaccessible to residents. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPA observed emergency food and water located in a locked storage room near the kitchen area. BEDROOMS: 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. 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: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FINE GOLD MANOR RETIREMENT	FACILITY NUMBER: 197606845
	VISIT DATE: 03/16/2022

NARRATIVE

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Continued from LIC 809.

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid surfaces. At 12:47 p.m., hot water measured at 108.7-degree Fahrenheit. Additionally, the downstairs common restroom water temperature measured at 112.3 degree Fahrenheit.

OUTDOOR SPACE: 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.

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 in the hallway near the boiler room.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.
LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were observed at this time. Exit interview conducted with Administrator. Report issued and a copy of the report will be provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC809 (FAS) - (06/04)

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