197607582-10-31-2024-11-AS-DLEE-DAKUBE-20241031152612

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607582
Report Date: 10/31/2024
Date Signed: 10/31/2024 03:26:23 PM

Document Has Been Signed on 10/31/2024 03:26 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	PALM GARDENS WELLNESS HOME		FACILITY NUMBER:	197607582
ADMINISTRATOR/ DIRECTOR:	DARYLLEN STONE		FACILITY TYPE:	740
ADDRESS:	5651 E WALTON STREET		TELEPHONE:	(562) 421-5577
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	10/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:07 PM
MET WITH:	Anchie Reyes		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

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On October 31, 2024, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced required annual visit using the CARE Inspection Tools. LPAs met with staff Ma. Trinidad Fernandez and explained the purpose of this visit. Subsequently, administrator Anchie Reyes arrived to assist with the visit. The facility is licensed to serve (6) elderly residents ages 60 and above. All rooms are cleared for non-ambulatory residents. The facility is approved for (2) hospice residents. There are currently (6) residents in care.

Structure 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..

Physical Plant LPA and Administrator toured the facility inside and outside. LPA observed there were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. LPA observed that facility had required postings: ombudsman poster, see something say something poster, emergency numbers, clients rights, facility sketch.

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Eva M Alvarez	TELEPHONE: (323) 629-7047
Deborah Lee	TELEPHONE: (424) 544-1051
	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PALM GARDENS WELLNESS HOME	FACILITY NUMBER: 197607582
	VISIT DATE: 10/31/2024

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Bedrooms LPA inspected all (5) bedrooms. All bedrooms were observed to have the required furniture including beds, dressers, night stands with lamps, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting.

Bathrooms LPA inspected the facility bathrooms. In the resident’s bathroom the toilet, faucets, and shower were fully operational. All safety handrails were securely fastened. LPA observed the showers to be clean and free of mold or mildew. The shower had a nonskid material in bottom and shower chair. Resident’s toiletries are secured in a cabinet under the sink. The water temperature measured 117-degrees Fahrenheit. The toilet and faucets are operational. Both bathrooms were observed to be clean, in good repair and within Title 22 regulations.

Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens, towels, and blankets in the hall closets.

Kitchen LPA inspected the kitchen and observed all appliances to be in good working repair. LPA observed knives and additional sharps to be secured in locked cabinet above refrigerator and are inaccessible to residents. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. Cleaning products and toxins were secured in detached garage area and are inaccessible to the residents in care.

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SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Deborah Lee	TELEPHONE: (424) 544-1051
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PALM GARDENS WELLNESS HOME	FACILITY NUMBER: 197607582
	VISIT DATE: 10/31/2024

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Common Rooms In the living room/dining room combo: LPA observed 5 recliners, mounted TV, a bookshelf with various books, a six seated dinning table in the dinning area.

Safety LPA observed and tested smoke/carbon monoxide detectors to be fully operable. LPA observed ( 2 ) fully charged fire extinguisher mounted on the wall, last serviced on 8/30/2024. The last emergency drill was conducted on 08/09/2024 LPA inspected the First Aid kit and found it contained an ample supply of required items: Scissors, tweezers, gauze, disinfectant wipes, band aids and a manual. LPA observed all exits to be clear and easily accessible. All toxins are inaccessible to the residents in care. There are no firearms or ammunition stored on the premises.

Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked cabinet that is inaccessible to Residents in care.

Files LPA reviewed ( 5 ) resident files and found the contained all the necessary documentation. LPA reviewed four ( 4 ) staff files and found they contained the required documentation, certification, and training. Liability Insurance expires on 3/10/2025

Infection Control During the visit, LPA observed PPE supplies are readily available to staff, and an additional 30-day supply of PPE was observed.

There were no deficiencies cited during today’s visit.

An exit interview was conducted with Assistant Administrator

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SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Deborah Lee	TELEPHONE: (424) 544-1051
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC809 (FAS) - (06/04)

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