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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607136
Report Date: 08/08/2022
Date Signed: 08/08/2022 04:20:41 PM


Document Has Been Signed on 08/08/2022 04:20 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:FOREVER YOUNGFACILITY NUMBER:
197607136
ADMINISTRATOR:MARTINIANA LAURETAFACILITY TYPE:
740
ADDRESS:1059 S. WINDSOR BL.TELEPHONE:
(323) 933-5051
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:6CENSUS: 5DATE:
08/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH: Martiniana LauretaTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Annual Required / Infection Control Visit to the above facility. LPA was met by Martiniana Laureta, Administrator and the purpose of today’s visit was explained.

The facility is licensed to serve (6) Non-Ambulatory residents ages 60 and above and hospice waiver for (2). There are currently (2) residents on hospice.

There are currently (5) residents in the facility. The facility consists of : 3 resident bedrooms, 2 bathrooms (1 staff bedroom), kitchen/ dining, living room and yard area. Physical plant inside and outside is in good repair.

LPA and Administrator Laureta toured the entire facility inside and out. Documents are posted as mandated. All resident rooms were checked and mattresses and bedsprings are in good repair, adequate lighting and closet space observed. All resident bedrooms contain the mandated furniture. Sufficient toiletries, linens towels and bedding for residents. LPA found the facility to have a comfortable temperature at time of visit. Exits were equipped with a sensor type alarm. The bathrooms are clean, sanitary and operational with grab bars and non skid mats in place. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents in a locked file cabinet. All disinfectants, toxins, knives and cleaning solutions were locked an inaccessible to residents. Food supply was adequate for 2-day perishable and 7-day non-perishable. Hot water temperature is 112 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to clients, Exit, walkways and/or passageways, are free of debris and/or hazards.

SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: FOREVER YOUNG
FACILITY NUMBER: 197607136
VISIT DATE: 08/08/2022
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The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms bathrooms and hallways.
  • Facility is conducting COVID-19 screening for all visitors.
  • Residents are able to use a designated isolation room that will be used as isolation room if a COVID-19 positive case should arise.
  • 30 day supply of medication for residents
  • Facility has an adequate amount of PPE and facility has enough PPE for 1 week .
  • Residents were socially distanced according to local public health guidelines.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Hand Sanitizer: Available throughout the facility for resident/ staff use.
  • High touch areas are disinfected twice a day and as needed.
  • The resident's temperature is checked and logged daily and if they are exhibiting any symptoms.
  • Staff temperatures are checked and logged daily and if they are exhibiting any symptoms.
  • Staff and residents are tested every 2 weeks and if exhibiting any COVID-19 symptoms.
  • All residents and staff are fully vaccinated and have received both booster vaccines for COVID-19.


According to the California Code of Regulations, LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator Martiniana Laureta and a copy of report provided.

SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC809 (FAS) - (06/04)
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