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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607582
Report Date: 08/08/2022
Date Signed: 08/09/2022 06:51:37 AM

Document Has Been Signed on 08/09/2022 06:51 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 HOMEFACILITY NUMBER:
197607582
ADMINISTRATOR:DARYLLEN STONEFACILITY TYPE:
740
ADDRESS:5651 WALTON STREETTELEPHONE:
(562) 421-5577
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 6DATE:
08/08/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Anchie ReyesTIME COMPLETED:
03:41 PM
NARRATIVE
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On 08/08/22 Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management - annual continuation visit at this facility. Upon arrival at the facility, LPA was greeted by assistant administrator Anchie Reyes and conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection.

During the inspection, smoke detectors and carbon were tested and found in working condition. The facility has a working lineline phone. A review of Medication Administration Record (MARs) revealed to be maintained accurate and in order.


DEFICIENCIES:
LPA reviewed service records for resident #2 (R2) who was admitted on 07/05/22 under hospice care and failed to notify CCL within five days of admittance according to Hospice Care Waiver Regulation 87632. The administrator is being cited according to Administrator's Qualifications Regulations 87405 resulting in multiple deficiencies cited.

California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D).

An exit interview was conducted and a copy of the Evaluation Report and Appeal Rights were provided to Anchie Reyes.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
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 08/09/2022 06:51 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/08/2022 at 02:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALM GARDENS WELLNESS HOME
FACILITY NUMBER: 197607582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2022
Section Cited
CCR
87405(b)(2)

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87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2 )Knowledge of and ability to conform to the applicable laws, rules and regulations.
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The licensee will create a plan to ensure that the administrator performs knowledge of and conforms to applicable laws, rules and regulations. The licensee to review Title 22 87405. Plan of correction will be submitted by POC due date: 08/15/22
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This requirement was not met as evidenced by:
Based on interview and record reviews the Licensee/Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited, which poses a potential health and safety risk to residents in care.
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Type B
08/15/2022
Section Cited
CCR87632(2)

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87632 Hospice Care Waiver
(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services...
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Licensee will adhere to Title 22 - 87632 regulations and will ensure to notify CCL of hospice residents in care. Licensee will ensure to review this regulation and present proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 08/15/22.
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This requirement is not met as evidence by:
Based on interview with licensee, Licensee failed to report to CCL with resident R2 admitted at this facility as of 07/05/22. This violation possess a potential Health and Safety risk to residents in care.
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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
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022


LIC809 (FAS) - (06/04)
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