197607136-5-30-2024-28-AS-TRES-D5RUVV-20240530155546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607136
Report Date: 05/30/2024
Date Signed: 05/30/2024 03:55:59 PM

Document Has Been Signed on 05/30/2024 03:55 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	FOREVER YOUNG		FACILITY NUMBER:	197607136
ADMINISTRATOR:	MARTINIANA LAURETA		FACILITY TYPE:	740
ADDRESS:	1059 S. WINDSOR BL.		TELEPHONE:	(323) 933-5051
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90019
CAPACITY:	6	CENSUS:	DATE:	05/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:18 AM
MET WITH:	Administrator Laureta		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) Tyler Reyes conducted an unannounced required annual inspection using the CARE tools. LPAs met with Administrator Martiniana Laureta and explained the reason of the visit. The facility is a Residential Facility for the Elderly(RCFE) licensed to serve 6 clients age range 59 and over, non-ambulatory only and an approved hospice waiver for 6. Currently, there are there are two (2) residents placement. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs (SHN). During the visit LPA observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. There is a visitor sign-in/ screening station located in the main entrance. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan.Bathrooms have hand washing signs, soap and paper towels. Facility Administrator is adhering to infection control requirements. Refer to LIC 809C for continuation of report

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FOREVER YOUNG	FACILITY NUMBER: 197607136
	VISIT DATE: 05/30/2024

NARRATIVE

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Operational Requirements: Fire Drills are conducted every three months, the last fire drill was conducted on 04/09/2024. Emergency Disaster/ Earthquake Drills are also conducted every three months and the last one was conducted on 04/09/2024. Facility Administrator is adhering to operational requirements.

Physical Plant & Environment Safety: The home is located in a residential area, the single-story facility consisting of: three bedrooms, living room, kitchen, dining room, laundry area, and office area. All resident rooms were checked. All resident beds have the required linens which were in good condition at the time of the visit. All bedrooms had sufficient closet/ storage space. Bathrooms are clean and operational and were observed to be within Title 22 regulations. Facility toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients. Bathrooms are clean, sanitary and operational with grab bars and non skid mats in place. Water temperature properly measured at 111F*. Facility temperature was comfortable throughout the facility. LPA observed the facility to be clean and in good repair. 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. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher is fully charged. Exit, walkways and/or passageways, front yard is free of debris and/or hazards. A shaded area with chairs is provided for residents in the front porch of the facility

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator certificates expires 3/27/2025.

Refer to LIC 809C for continuation of report

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FOREVER YOUNG	FACILITY NUMBER: 197607136
	VISIT DATE: 05/30/2024

NARRATIVE

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Resident Records-Incident Reports: LPA reviewed Client files for R1 through R6. Resident files are maintained at the facility and have the following documents in their files : Admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment/Appraisals, hospice care plans, and emergency information.

Resident Rights-Information: RCFE complaint poster and Personal rights were observed posted in the facility. Per Facility Administrator, facility provides wi-fi services for facility residents.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician order for modified diet is on file. Sanitation practices and kitchen cleanliness was observed.

Incidental Medical Services: Six (6) centrally stored 30-day supply of medications were reviewed. Medical and dental transportation is provided by facility and family members.

Disaster Preparedness: Emergency and Disaster Plan LIC610E is in place. The last quarterly fire/emergency drill was completed on 04/09/2024.

Residents with SHN : Two (2) residents receive hospice care.Appraisals were observed in resident files. No residents have prohibited health conditions.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC 809D for details. An exit interview was conducted. This report and appeal rights were discussed and provided to facility Licensee/Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/30/2024 03:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FOREVER YOUNG	FACILITY NUMBER: 197607136
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

87465(h)(6)

This requirement is not met as evidenced by: Per review of Resident#1 (R1)'s medication sheet, R1's May 2024 medication sheet did not record R1s missed medication. As review of Resident #1 (R1), resident's medication log did not match with the number of pills/ medication administered. Licensee did not document regarding the Rx discrepancy. Staff#2 stated to LPA that the reason for not documenting the missed medication for the May 2024 Medication Sheet was just missed. LPA made copies of R1s May 2024 Medication Sheet, Physician's Report and took pictures of the 2024 Medication Sheet and Medication.
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator Laureta, agreed to provide (1) additional medication in-service training to all staff and provide proof to the department and notify physician; (2) review Title 22, Section 87465 and provide a signed statement indicating the review of this section detailing how to prevent future medication errors by the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC809 (FAS) - (06/04)

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