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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609826
Report Date: 01/28/2022
Date Signed: 01/28/2022 12:57:10 PM

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:COHEN, YEHUDAHFACILITY TYPE:
740
ADDRESS:1025 N FAIRFAX AVETELEPHONE:
(323) 656-7900
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:130CENSUS: 38DATE:
01/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Yonathan Isaacs - Executive DirectorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Gary Tan met with Executive Director Yonathan Isaacs for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit.

A tour of the physical plant was conducted at 10:06 AM and the following were noted:

There is only one entrance being utilized at the facility, the front main entrance door. There are required poster posted at the main door. Screening area is located immediately upon entrance. All visitors/resident and staff are required to sign. There is also a sign in sheet, hand sanitizer, gloves and masks available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

The facility had submitted and approved Mitigation plan.

There are hand sanitizing stations and hand sanitizers all over the facility. There are signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in common bathrooms, elevators and all over the common areas of the facility. The facility has a designated visitors' area in the front yard. The facility has sufficient stock of PPE in the storage room.

The facility is fire cleared for One thirty (130) non-ambulatory residents, eight (8) of which may be bedridden. Hospice waiver is approved for thirteen (13) residents.

(continued to LIC 809-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
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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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
VISIT DATE: 01/28/2022
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(continued from LIC 809)

Common areas, including the activity rooms, mail room, dining rooms and library appeared clean and were properly furnished. All common rooms are temporarily closed due to the outbreak at the facility. The kitchen appeared clean and the appliances and fixtures functional. Residents do not have access to the kitchen; dangerous items are properly stored and inaccessible to residents. Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. The patios and balconies have proper furnishings. The medications were locked in the medication carts, properly labeled and stored. Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings, working signal system, grab bars and non-skid surfaces in the bathrooms. Hot water temperature in random resident bathrooms were checked and measured a range of 107.6°F to 112.3°F.

Fire extinguishers are located throughout the facility hallways on both floors and were last serviced on 02/19/21. There are First aid kits in the medication room located in the ground floor. The facility's smoke alarms are hard wired and interconnected and back up and tests are done in house on a monthly basis.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
LIC809 (FAS) - (06/04)
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