197607174-12-29-2023-11-AS-DESA-CYYRUS-20231229122026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607174
Report Date: 12/29/2023
Date Signed: 12/29/2023 12:20:31 PM

Document Has Been Signed on 12/29/2023 12:20 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
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: 5	DATE:	12/29/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Nawal Sfeir, Business Manager		TIME COMPLETED:	09:59 AM

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On 12/29/2023 at 9:00 am Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection.

LPA met with House Manager, Nawal Sfeir, and explained the purpose of the visit. Together we toured the facility.The facility has Five (5) Residents in care and three (3) staff present at the time of visit. The Residential Care Facilities for the Elderly (RCFE) facility has five (5) non-ambulatory residents, three (3) residents with dementia and one (1) resident in hospice. The facility is a single-story home in a residential neighborhood. The facility consists of six (6) bedrooms, six-point five (6.5) bathrooms, one (1) kitchen, one (1) dining room, one (1) sitting room, one (1) living room and front and back patio sitting areas.

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.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 resident’s room fully stocked. 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. The water temperature in the bathrooms measured between 111.9- and 115.0-degrees Fahrenheit. LPA toured the outside of the facility. All appliances in the kitchen are in good working order except the stove is missing a knob. The refrigerator was stocked with an ample supply of perishable foods. The cupboards were stocked with ample supply of nonperishable food. The knives were locked in a drawer. Facility Evaluation Report LIC-809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

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: 12/29/2023

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The cleaning supplies were locked in a cabinet in the kitchen. The kitchen sink water temperature measured at 113 degrees Fahrenheit, guess bathroom hot water temperature measured at 112 degrees Fehrenheit, and bedroom 3 hot water temperature measured at 110 degrees Fahrenheit. The telephone, which is a landline ((310) 454-3583), is working. Exit plan and emergency phone numbers are posted. The fire extinguishers are fully charged. The last emergency drill was on 06/20/2023. LPA checked the smoke detectors with sprinklers and carbon monoxide detectors. Egress devices are working on all the doors exiting the facility. The medications cabinet is located in the kitchen and medications are in a locked cabinet and inaccessible to residents. LPA checked three (3) of the resident medications and the MARs. All the medications were within title 22 regulations. LPA interviewed three (3) staff members at the time of the visit. The First Aid kit was fully stocked, and a manual was with it. LPA reviewed Six (6) out of Seven (7) staff member files. LPA reviewed Five (5) out of Five (5) residents records. 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. LPA reviewed facility’s Liability Insurance: Expires 06/13/2024. LPA observed cameras in the common areas and in the resident bedrooms. Cameras are to monitor the clients per the family’s request.LPA confirmed that there was one (1) resident taking Oxygen. LPA confirmed there are three (3) non-ambulatory present at the time of visit.

There were deficiencies observed during today's inspection.

An exit interview was conducted with Nawal Sfeir and a hard copy of the report was furnished.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC809 (FAS) - (06/04)

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