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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609826
Report Date: 06/12/2023
Date Signed: 06/12/2023 04:39:56 PM


Document Has Been Signed on 06/12/2023 04:39 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:GARDEN OF PALMSFACILITY NUMBER:
197609826
ADMINISTRATOR:GINSBURG, MENACHEMFACILITY TYPE:
740
ADDRESS:1025 N FAIRFAX AVETELEPHONE:
(323) 656-7900
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:130CENSUS: 81DATE:
06/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:31 PM
MET WITH:Rena HirschTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) LaQueena Lacy conducted a Case Management visit in conjunction with complaint #31-AS-20230602143343. LPA arrived at the facility on 06/12/2023 at 11:48am. LPA meet with Rena Hirsch the Outreach Ambassador staff #1 (S1) and explained the purpose of the visit.

LPA and S1 conducted a physical plant tour at 11:57am.

At 12:07PM LPA observed the medication cart top drawer slightly ajar, unlocked, and accessible to residents in care. LPA pulled the slightly ajar drawer fully open and observed three (03) different of medication in plastic dispensing cups filled with medication inside of a plastic divider and one (01) cup of filled medication sitting inside of the medication drawer filled with gloves, apple sauce, television remote, and extra plastic medication cups. Upon LPAs observation it was brought to S1s attention and they observed the medication cart top drawer open with medications accessible to resident in care. LPA conducted interviews with S2 on 06/12/2023 at 3:15pm and they confirmed that they left the drawer open by mistake and is aware of the danger of medication being left unattended. S2 affirm they will double check that all medication is locked and inaccessible to residents.

Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit. See LIC 809-D.

Exit interview conducted, copy of report and appeal rights issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023
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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Document Has Been Signed on 06/12/2023 04:39 PM - 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: GARDEN OF PALMS
FACILITY NUMBER: 197609826

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2023
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care(h)The following requirements shall apply to medications which are centrally stored(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons... This requirement is not met as evidenced by:



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Administrator will conduct in-service with all staff on centrally stored medications, and submit the safety awarenes in-service conducted on 06/07/2023 by email to LPA by POC due date.
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Based on observations the medication cart was unlocked and accessible to residents. The Licensee did not ensure that the medication cart storing centrally stored medication was locked and inaccessible to resident in care. This poses an immediate health and safety
hazard 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023
LIC809 (FAS) - (06/04)
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