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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609826
Report Date: 10/13/2022
Date Signed: 10/13/2022 04:01:53 PM

Document Has Been Signed on 10/13/2022 04:01 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:MENACHEM GINSBURGFACILITY TYPE:
740
ADDRESS:1025 N FAIRFAX AVETELEPHONE:
(323) 656-7900
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 130CENSUS: 51DATE:
10/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rena HirschTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility on 10/13/2022 at 11:05am to conduct a Case Management visit for the purpose of gathering information regarding a self-reported incident report regarding resident #1 (R1) ingesting hand sanitizer and having an ethanol level of 0.037. LPA met with staff Rena Hirsch and explained the purpose of this visit. LPA conducted Interviews with staff at 11:30am and resident #1 at 1:46pm. Interviews with staff confirmed all housekeeping carts are to be returned to the storing room on the first floor when not being attended by staff, and all bedrooms are locked when residents are in the common areas. During the interviews staff #1 (S1) stated “ the cart was left in a vacant room while taking a break, but the door was locked when leaving the room”. At approximately 11:15am LPA inspected eleven (11) random rooms in the Soul Memory Care to be locked and inaccessible to residents and did not observe any hand sanitizer or other toxins located in any of the bedrooms/bathrooms or any unattended housekeeping carts. The housekeeping cart storing room is located on the first floor and was observed at 2:38pm to be locked and inaccessible to residents storing cleaning supplies, toiletries, and PPE items. Upon record review R1 has progressive dementia and wandering behaviors. The facility conducted an in-service with memory care staff and will conduct the same training with remaining staff and additional training for all staff. Based on interviews, observation and record review a civil penalty will be assessed and a deficiency cited.

Exit interview conducted, copy of report and appeal rights issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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 10/13/2022 04:01 PM - It Cannot Be Edited


Created By: LaQueena Lacy On 10/13/2022 at 03:10 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN OF PALMS
FACILITY NUMBER: 197609826

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2022
Section Cited
CCR
87705(2)(f)(2)

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87705Care of Persons with Dementia (2) Safety measures to address behaviors such as wandering,...ingestion of toxic materials.(f)...inaccessible to residents with dementia:(2)...and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
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 Licensee has conducted in-service training on Safety Measures in Memory Care to memory care staff, but will provide in-service to all staff, and additional training to all staff regarding toxic substances in dementia care. Licensee will submit a list of next working date the in-service will be conducted. Will submit to LPA by POC due date
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Based on interviews, observation and record review staff failed to secure the housekeeping cart and ensure that all toxic substances were inaccessible to dementia resident in care. This violation poses an immediate health and safety risk to client 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 Margaryan
LICENSING EVALUATOR NAME:LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
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