198201597-7-10-2023-11-AS-PBUR-CTLRW6-20230710132238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198201597
Report Date: 04/21/2022
Date Signed: 07/10/2023 01:22:42 PM

Document Has Been Signed on 07/10/2023 01:22 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ANA'S ELDERLY CARE HOME		FACILITY NUMBER:	198201597
ADMINISTRATOR:	RAMOS, ANA MARIA		FACILITY TYPE:	740
ADDRESS:	3906 TULLER AVENUE		TELEPHONE:	(310) 398-9305
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90230
CAPACITY:	6	CENSUS: 1	DATE:	04/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:13 AM
MET WITH:	Ana Ramos		TIME COMPLETED:	02:17 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 Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with Licensee Ana Ramos and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan Report. There is currently one (1), resident in placement. The facility's annual fees are current. The following Domain will be observed and reviewed: Infection Control Practices "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." The facility is a single-family home located in a residential neighborhood. Licensee/Administrator Ana Ramos and LPA Bunker toured the facility which consisted of the following: Living room, dining room, 2 kitchens, 5 bedrooms, 4 bathrooms, office area, laundry room, den/family room, shaded area, indoor/outdoor activity areas, and a detached garage. The front and back yard landscape is in good condition at the time of the visit. See continued LIC809-C on page 2

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANA'S ELDERLY CARE HOME	FACILITY NUMBER: 198201597
	VISIT DATE: 04/21/2022

NARRATIVE

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Continued LIC809-C page 2

Documents are posted as mandated. Bedrooms contain the required furniture, Bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-skid surfaces mats. The kitchen was observed for the ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are locked in the hallway closet, and records are current. Common areas were observed for the ability to safely serve the needs of the residents, including cleanliness, and clearness of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, hot water temperature measured at 111 degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguishers are fully charged, adequate linen supply, the facility telephones are working. The resident's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting. The facility conducted a fire drill on 10/15/2021.

There were no deficiencies cited.

Exit interview conducted.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC809 (FAS) - (06/04)

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