197607136-6-24-2025-28-AS-LDLN-DHXR9N-20250624124951

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607136
Report Date: 06/24/2025
Date Signed: 06/24/2025 12:51:07 PM

Document Has Been Signed on 06/24/2025 12:51 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/ DIRECTOR:	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: 6	DATE:	06/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:25 AM
MET WITH:	Administrator Joni Ramos		TIME VISIT/ INSPECTION COMPLETED:	01:00 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) Luis De Leon conducted an unannounced required annual inspection visit. LPA met with Administrator Joni Ramos and explained the reason for the visit. Administrator Ramos contacted Licensee Laureta Martiniana who joined the visit a short time after. The facility is licensed to serve six (6) residents 60 years and over. The facility is approved for six (6) non-ambulatory residents and six (6) hospice waivers. LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. LPA De Leon toured the facility with assistance of administrator Ramos: FACILITY PHYSICAL PLANT The facility is in a residential area and is made up three (3) resident bedrooms, one (1) staff bedroom, three (3) full bathrooms for residents’ use, kitchen, activity area, laundry located in backyard, dining room, living room, front and backyard. There were no body of water observed in the property. REVIEW OF FILES LPA reviewed six (6) out of (6) Resident files which consisted of Admission Agreements, Identification and Emergency Info, Physicians Report, Consent Report, Individual Program Plan, Personal Rights, and Centrally Store Medication. LPA reviewed four (4) staff files which consisted of Personnel Report, Health Screening, Criminal Record Statements, Fingerprint Clearance, Training, First Aid and CPR. Emergency Disaster Preparedness, Operation Plan, Hospice and Dementia care plans. Report continues on page LIC-809C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 06/24/2025

NARRATIVE

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All resident rooms were inspected, and LPA observed resident beds, dresser, and chairs in good repair. Adequate linen and personal hygiene supplies are observed with enough closet space for resident’s personal belongings. Sufficient space to accommodate both indoor and outdoor activities was observed. During today’s visit, LPA observed residents participating on chair exercises and karaoke. Licensee stated that residents also participate on board games, reading, and community walks. Walls and floors are in good repair. Common areas are observed for the ability to safely serve the needs of the residents without obstruction. Smoke detectors and carbon monoxide detectors are tested and operational in resident’s rooms and common areas. Facility temperature was comfortable. Bathrooms are clean and operational. The hot water temperature was tested in the residents' bathrooms and was within the required range of 105-120 degrees F. Showers were free of mold/mildew, had adequate lighting, and there are sufficient toiletries that are accessible to residents. Last fire drill was done on 4/4/25 and earthquake drill on 4/9/25. One (1) Fire extinguisher is fully charged, last serviced on 5/30/25. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Physician order for modified diet is on file. Sharps are locked under stove and are inaccessible to resident. Cleaning supplies and grooming supplies were observed locked in cabinet. Backyard and front yard are clean, free of debris. No large bodies of water were observed. Facility provides telephone landline and internet for the residents. There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Staff have sufficient on-going training that meets the annual requirement. The medications are centrally stored and in their original containers. LPA reviewed six (6) out of three (6) residents’ medications. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during today’s visit. Exit interview was held and a copy of the report was given to Administrator Laureta Martiniana.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025

LIC809 (FAS) - (06/04)

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