197610358-4-5-2024-31-AS-PKHN-D42T97-20240405143127

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610358
Report Date: 04/05/2024
Date Signed: 04/05/2024 02:32:47 PM

Document Has Been Signed on 04/05/2024 02:32 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LILY & ROSE SENIOR LIVING INC		FACILITY NUMBER:	197610358
ADMINISTRATOR:	JOCOM, JOANNE		FACILITY TYPE:	740
ADDRESS:	287 VENTURA STREET		TELEPHONE:	(714) 458-5508
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	6	CENSUS: 4	DATE:	04/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:			TIME COMPLETED:	03:00 PM

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At 10:00am Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Huma Rahimi conducted an unannounced annual inspection at the facility mentioned above. LPAs met with facility staff Karen Villagracia and the facility administrator Joanne V Jocom who arrived later. At approximately 10:10am physical tour was conducted with the staff, LPAs observed the following:

The facility is approved for six (6) ambulatory residents, of which five (5) may be Non-ambulatory- with designated bedrooms #2, #3, and #4. Facility has Hospice waiver for six (6) residents.

Kitchen: At approximately, 10:15am LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Canned non expired food was stored in kitchen cabinets. LPAs observed knives and toxins locked under the kitchen sink; however, one of the knives was observed unlocked in the kitchen drawer. The facility has a working gas stove, microwave, refrigerator and freezer.

Bedrooms: At approximately 10:20am LPAs checked the bedrooms. There are four (4) bedrooms designated for 4 residents use. All rooms were observed to have sufficient lighting, and are properly furnished, clean and have appropriate bedding and linens. There is enough linens to be change every week or when necessary in a cabinet in the hallway

Bathrooms: At 10:30am LPAs observed two (2) bathrooms, all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. Hot water was measured at 111.9 F. Bathroom # two (2) is designated for staff use only and locked not accessible for resident's use. LPAs observed appropriate grab bar and had non-skid mat. All trash cans in bathrooms had fitted lids to protect from cross contamination.
Continue on LIC 809C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LILY & ROSE SENIOR LIVING INC	FACILITY NUMBER: 197610358
	VISIT DATE: 04/05/2024

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Medications: At approximately, 10:35am LPAs observed medications are centrally stored and locked in the hallway closet on the top shelves. Resident and staff records also stored in locked hallway closet. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the resident's doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.

The laundry room: is located in the hallway without any locking mechanism. LPAs observed all detergents were unlocked and accessible to residents in care.

Common Areas: The facility maintains a comfortable temperature at 71°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility found. Dual smoke supplies were tested and carbon monoxide detectors were located throughout the facility and observed to be operational. No issue with fire clearance. There is a functioning telephone/landline on the premises. An emergency exit plan/sketch is posted near each entrance/exit wall with other posting requirements. There is a fire extinguisher by the kitchen area were last purchased on 01/20/2024.

Outside areas: At approximately, 10:50am LPAs toured the outside area of the facility. Exit area is free of obstructions and hazards. LPAs checked inside of the locked basement storage where enough PPE supplies were stored, and it was used for facility maintenance purposes. LPAs discussed the importance of maintaining the care and supervision to meet the needs of residents. The facility does not have a swimming pool or body of water. There is no garage only parking port.

Between 11:00am to 1:00pm, LPAs reviewed records of four (4) clients and four (4) staff. Clients and staff
records appeared to be complete and updated.

Administrative: LPAs collected Administrator Certificate, infection control, LIC 500, LIC 9020.

Citations issued during this visit.
Appeal rights explained.
Exit interview conducted. Copy of report printed and handed to Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/05/2024 02:32 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LILY & ROSE SENIOR LIVING INC	FACILITY NUMBER: 197610358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

87309 Storage Space (a) Disinfectants, cleaning solutions…and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Cleaning agents and chemicals were found to be accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2024
	Plan of Correction
1 2 3 4	Administrator will properly train staff to keep cleaning agents and chemicals inaccessible to residents and proof of training will be sent to LPA by e-mail by 04/08/2024.

Type A

Section Cited

CCR

87705(f)(1)

87705(f)(1) Care of persons with Dementia The following shall be stored inaccessible to residents with dementia:(1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs observed sharp objects drawer unlocked. This poses/posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2024
	Plan of Correction
1 2 3 4	Staff locked the knife immediately in the kitchen under the sink. Licensee is to conduct training on how to properly store knife and maintaining them inaccessible to residents. Proof of training is to be submitted to LPA by e-mail by 04/08/2024.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

LIC809 (FAS) - (06/04)

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