197610403-9-12-2024-31-AS-RCOR-D92U4F-20240912151506

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610403
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:17:55 PM

Document Has Been Signed on 09/12/2024 03:17 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:	GARDEN OF PALMS LA		FACILITY NUMBER:	197610403
ADMINISTRATOR:	HIRSCH,RENA		FACILITY TYPE:	740
ADDRESS:	1025 N FAIRFAX AVE		TELEPHONE:	(323) 656-7900
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	130	CENSUS: 106	DATE:	09/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Adam Syncheff		TIME COMPLETED:	03:30 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	On 09/12/24, 9:45 AM, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced Annual inspection of the Facility. LPA met with Facility Administrator, Adam Syncheff, and reason for the visit was disclosed. Facility is licensed as a two-story building. Fire clearance approved for (122) non-ambulatory, and an additional eight (08) bedridden; Hospice waiver for thirty (30). There are currently three (3) residents receiving hospice care services, and one (1) bedridden. At 10:30 AM, LPA conducted a tour of the physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Facility provides dementia care; LPA observed delayed egress system working properly throughout all access points of the facility. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 76.0°F. within the required range. The facility maintains approved Mitigation and Infection Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted in June 2024. Fire Detection/Protection system is present in the facility. Multiple dual smoke/carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire alarm system was tested at the time of LPA visit and is working properly. Fire drill last conducted June 2024. [LIC 809C -Continued]

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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: GARDEN OF PALMS LA	FACILITY NUMBER: 197610403
	VISIT DATE: 09/12/2024

NARRATIVE

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Kitchen: At 11:25AM, LPA observed kitchen as clean, commercial refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are properly stored and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons, were observed near any food areas.

Medications: Medication room is located on first floor by the Administrator’s office; LPA observed room as locked and inaccessible to residents. Inside the room, medications are properly labeled, and stored in secured cabinets. Resident medication documentation and distribution records appear to be complete. First aid kits were observed on carts stored in the medication room.

Commons: At Activity room, dining room, and library observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed.

Resident records: A total of eight (8) Resident files were reviewed for current IPP and/or needs and services plans, physician report, admission agreements, pre-admission appraisals\reappraisals, centrally stored medication logs, and resident identification. Resident records appeared to be complete and current.

Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date.

Exit interview conducted/Copy of report given to Administrator, Adam Syncheff.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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