197610403-7-14-2023-31-AS-JGTN-CTQTN7-20230714145217

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610403
Report Date: 07/14/2023
Date Signed: 07/14/2023 02:52:48 PM

Document Has Been Signed on 07/14/2023 02:52 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GARDEN OF PALMS LA		FACILITY NUMBER:	197610403
ADMINISTRATOR:	GINSBURG, MENACHEM		FACILITY TYPE:	740
ADDRESS:	1025 N FAIRFAX AVE		TELEPHONE:	(323) 656-7900
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	130	CENSUS: 87	DATE:	07/14/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Rema Hirsch - Executive Director		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Gary Tan and MIchael Cava conducted an unannounced Prelicensing visit to this facility with Component III orientation. This is a change of ownership. It has been operating as Garden of Palms, License #197609826. Applicant is Fairfax Gardens Operations LLC. Fire clearance inspection was done on 06/06/23 with the approved capacity of 130 Non-ambulatory residents, eight (8) of which may be bedridden. LPAs met with Executive Director Rema Hirsch and explained the reason for the visit. Regional Director Nirjara Acharyan arrived around 30 minutes later. A tour of the physical plant was conducted with Ms. Hirsch and John Garcia III, Director of Maintenance at 10:35 AM for compliance with safety, maintenance and operational requirements. Smoke detectors and Carbon Monoxide detectors is tested monthly. Fire Equipment were last tested on 01/02/23. Facility disaster drills are conducted quarterly and last conducted on 05/18/23. Fire extinguishers were fully charged and were last inspected on 02/28/23. Bedrooms: LPA inspected twelve (12) randomly selected resident bedrooms on both floors and Memory Care and Assisted Living. LPAs observed bedrooms to be properly furnished and had adequate lighting. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: LPAs observed all bathrooms in each bedroom to be clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured between 113.5°F to 119.6°F (continued to LIC 9099-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN OF PALMS LA	FACILITY NUMBER: 197610403
	VISIT DATE: 07/14/2023

NARRATIVE

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(continued from LIC 9099)

Kitchen: The kitchen appliances and fixtures appeared functional. LPAs observed refrigerated and frozen foods were stored at proper temperatures. LPA observed temperature log on wall next to the fridge door. There was a sufficient amount of perishable and non-perishable foods properly stored in a room adjacent to the refrigerator. Emergency food supply is kept in the storage in the basement and appeared to be sufficient for the current census. The facility menu appears to meet the daily dietary needs for residents. There were no pesticides or poisons observed near any food areas.

Common Areas: These included the activity rooms, library, dining rooms and reception area. LPAs observed that there was an ongoing activity during the visit. The common areas were checked for cleanliness and furniture was checked for functionality. All areas were clean, sanitary and in good repair. The facility was observed to be kept at a comfortable temperature.

Medication: LPA observed medication room to be locked and inaccessible to residents. The medications were locked in the medication carts, properly labeled and stored. There are complete first aid kits in the medication room.

Surrounding Grounds (Outdoors): There were shaded patio areas with proper furniture for outdoor use in the front and center of the facility. There are no bodies of water on the premises. Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. The patios and balconies have proper furnishings. LPA observed door alarms to be functioning properly at this time.

Component III was conducted on site with Executive Director Rema Hirsch.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA's recommendation for licensure.

Exit interview conducted and report signed and issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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