197607174-12-6-2022-11-AS-WGIS-CKZU3B-20221109141315

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607174
Report Date: 11/09/2022
Date Signed: 12/06/2022 08:31:50 AM

Document Has Been Signed on 12/06/2022 08:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	PALISADES VILLA, THE		FACILITY NUMBER:	197607174
ADMINISTRATOR:	TANIOS C. EL HABR		FACILITY TYPE:	740
ADDRESS:	16629 W. SUNSET BLVD.		TELEPHONE:	(310) 454-3583
CITY:	PACIFIC PALISADES	STATE: CA	ZIP CODE:	90272
CAPACITY:	6	CENSUS: 6	DATE:	11/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:14 AM
MET WITH:	Nana Sfeir		TIME COMPLETED:	02:15 PM

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On November 9, 2022 Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced annual required visit using CARE inspection tool. LPA Gibbs met with House Manager, Nawal Sfeir and explained the purpose of the visit. Together we toured the facility.

The facility has 6 Residents in care and 3 staff present at the time of visit. The facility has 3 non-ambulatory residents, 3 residents with dementia and 2 residents on hospice.

Structure The facility is a single story home in a residential neighborhood. The facility consists of 6 bedrooms, 6.5 bathrooms, kitchen, dining room, sitting room, living room and front and back patio sitting areas.

Physical Plant LPA walked the outside of the facility. LPA observed a backyard with shaded seating areas which is accessible to clients. There are additional chairs and tables on the front patio. LPA observed a water fountain in the front of the facility near the front door and another in the back in a corner both have running water. All exits/ walkways around the home were free of debris, hazards, or obstructions.

Bedrooms The facility has 6 private bedrooms. The bedrooms all had a chair, nightstand, lamp or overhead light that produced adequate lighting, a bed, dresser and closet with plenty of space. The beds have a mattress cover, top and bottom sheets, blanket, comforter, pillows and pillowcases. There are linens in each residents room fully stocked.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALISADES VILLA, THE	FACILITY NUMBER: 197607174
	VISIT DATE: 11/09/2022

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Bathrooms The toilets, showers and sinks are all in working order. The showers had nonskid mats or chairs and grab bars. LPA observed soap, paper towel and other hygiene products fully stocked. Water temperature in the bathrooms measured between 111.9- and 115.0-degrees Fahrenheit.

Kitchen All appliances in the kitchen are in good working order except the stove is missing a knob. The refrigerator was stocked with ample supply of perishable foods. The cupboards were stocked with ample supply of nonperishable food. The knives were locked in a drawer. The cleaning supplies were locked in a cabinet in the kitchen. The kitchen sink water temperature measured at 110.9 degrees Fahrenheit.

Emergency Phone Numbers, Exit Plan & Menu The telephone, which is a landline, is working. Exit plan and emergency phone numbers are posted. The fire extinguishers are fully charged. The last emergency drill was on 11/1/2022. LPA checked the smoke detectors with sprinklers and carbon monoxide detectors. Egress devices are working on all the doors exiting the facility.

Medications & First Aid The medications cabinet is located in the kitchen and medications are in a locked cabinet and inaccessible to residents. LPA checked 3 of the resident medications and the MARs. All the medications were within title 22 regulations. The First Aid kit was fully stocked and a manual was with it.

Record review LPA conducted file reviews for six (6) resident files and four (4) staff files. All files contained the required documentation.

LPA observed staff wearing masks, Visitor Log /Symptom screening Log, required Covid-19 Postings, 30 day supply of PPE and other required documents posted.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALISADES VILLA, THE	FACILITY NUMBER: 197607174
	VISIT DATE: 11/09/2022

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LPA reviewed facility’s Liability Insurance: Acord expires 2/19/2023

LPA observed cameras in the common areas and in the resident bedrooms. Cameras are to monitor the clients per the family’s request.

Deficiencies to cited: Oxygen signs posted outside of the rooms in use. There was a broken knob on the stove, all burners need to be able to turn on.

Exit interview conducted with Nawal Sfeir.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

LIC809 (FAS) - (06/04)

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