197607582-8-8-2022-11-AS-EDAT-CH4G8H-20220808050711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607582
Report Date: 08/07/2022
Date Signed: 08/08/2022 05:08:19 AM

Document Has Been Signed on 08/08/2022 05:08 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:	PALM GARDENS WELLNESS HOME		FACILITY NUMBER:	197607582
ADMINISTRATOR:	DARYLLEN STONE		FACILITY TYPE:	740
ADDRESS:	5651 WALTON STREET		TELEPHONE:	(562) 421-5577
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	6	CENSUS: 6	DATE:	08/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Anchie Reyes		TIME COMPLETED:	05:07 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	On 08/07/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with assistant administrator Anchie Reyes and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for two (2) hospice residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident's rooms, two (2) common bathrooms, living area, dining area, kitchen, a staff room, and outside covered patio area. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be clean and operational. The water temperature measured 107.6 F. A comfortable temperature of 73 degrees was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. The facility has two (2) fire extinguishers that were charged. A working landline telephone remains available. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2022

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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Document Has Been Signed on 08/08/2022 05:08 AM - 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALM GARDENS WELLNESS HOME	FACILITY NUMBER: 197607582
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87204(a)

Limitations -Capacity and Ambulatory Status

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation, interview and record review), the licensee did not comply with the section cited above. The facility is operating beyond the conditions specified on the license with resident #2 admitted on 07/05/22 as hospice resident. The licensee is only license for (2) hospice. Currently, there are (3) hospice residents. This violation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2022
	Plan of Correction
1 2 3 4	The licensee will adhere to Title 22 Section 87204(a). The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 08/08/22 with documentation for a request for hospice waiver increase.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation), the licensee did not comply with the section cited above. LPA identified cleaning solution with bleach on top of the the toilet. The facility is caring for dementia residents. The violation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2022
	Plan of Correction
1 2 3 4	The licensee will adhere to Title 22 Section 87309. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 08/08/22 with proof of hazardous chemicals are stored in locked cabinets. This citation was cleared during visit.

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/08/2022 05:08 AM - 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALM GARDENS WELLNESS HOME	FACILITY NUMBER: 197607582
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)(1)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA identified shower in bathroom #1 floor has stain marks resulting from wear and tear and appears unsanitary. This violation which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2022
	Plan of Correction
1 2 3 4	The licensee will adhere to Title 22 Section 87303(a). The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 09/07/22 with documentation for work order or inovice for new shower floor.

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2022

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: PALM GARDENS WELLNESS HOME	FACILITY NUMBER: 197607582
	VISIT DATE: 08/07/2022

NARRATIVE

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INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff tests and residents' vaccination along with daily temperature checks were conducted. The facility has an approved Mitigation Plan Report on file with CCLD.

DEFICIENCIES:
During a health and safety inspection, LPA observed at 3:01 pm a cleaning solution on top of the toilet in bathroom #1. LPA identified at 3:07 pm, shower floor in bathroom #1 unsanitary with black marks. During record review, LPA observed resident #2 admitted on 07/05/22 as a hospice resident. This exceeded beyond the conditions and limitations specified on the license. The facility is licensed for (2) hospice waivers and currently, the facility is operating with (3) hospice residents in care.

Due to time constraints, an annual continuation is required to complete a health and safety inspection at a later date.

Deficiencies are issued and an exit interview is conducted with Anchie Reyes. A copy of this report is provided along with the appeal rights.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2022

LIC809 (FAS) - (06/04)

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