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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201597
Report Date: 07/20/2017
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ANA'S ELDERLY CARE HOMEFACILITY NUMBER:
198201597
ADMINISTRATOR:RAMOS, ANA MARIAFACILITY TYPE:
740
ADDRESS:3906 TULLER AVENUETELEPHONE:
(310) 398-9305
CITY:CULVER CITYSTATE: CAZIP CODE:
90230
CAPACITY: 6CENSUS: 1DATE:
07/20/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Ana Maria Ramos TIME COMPLETED:
05:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Wong and Eva Alaverez conducted a facility visit for an annual Inspection. LPA met with administrator/licensee Ana Maria Ramos who assisted with this visit. The facility is licensed to serve Six (6) Non-Ambulatory (only) residents (age 60 and above) but now is only serving one (1) resident. The facility’s latest fire inspection was conducted on 07/06/17 by Culver City Fire Department. The fire extinguishers was observed to be fully charged. During today's visit, LPA's reviewed staff files, resident file, resident medication and toured the physical plant.

LPAs toured resident rooms, bathrooms, living room, kitchen, dining room, and patio. The patio was enclosed and no bodies of water were observed. Each bedroom is equipped with proper furniture and linen. The bathrooms were observed to be clean and operational w/ grab bars. The hot water temperature throughout the facility was measured at 111.6 degrees and met Title 22 Regulations. Carbon Monoxide and Smoke Alarms were tested and were operational. The medication is centrally stored and it was kept in a locked cabinet.

LPA observed food supply of two (2) days of perishables and seven (7) days of non-perishables. Storage areas for cleaning solutions, toxics, knives, and hazardous items were secured and made inaccessible to Resident.

The following deficiencies were observed to be in violation Under California Code of Regulations Title 22.
(refer to 809D).

An exit interview was conducted and a copy of this report was provided along with the appeals rights to facility
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2017
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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Document Has Been Signed on 07/10/2023 01:22 PM - It Cannot Be Edited


Created By: Christine Wong On 07/20/2017 at 05:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ANA'S ELDERLY CARE HOME
FACILITY NUMBER: 198201597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2017
Section Cited
87465(e)
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87465 (e) For any PRN medication for which a licensee provides assistance, there shall be a physician’s order on file and a label on the medication container. Specific information must be on both the order and the label. LPA observed Resident #1 all PRN medication include Allei-Tec 10mg, B12 Vitnamin 1000mcg, Calcium
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600mg and Spectra-Vite 365 tab.
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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:Patricia Magana
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2017


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/10/2023 01:22 PM - It Cannot Be Edited


Created By: Christine Wong On 07/20/2017 at 04:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ANA'S ELDERLY CARE HOME
FACILITY NUMBER: 198201597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2017
Section Cited
87476(e)
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87465 (e) For any PRN medication for which a licensee provides assistance, there shall be a physician’s order on file and a label on the medication container. Specific information must be on both the order and the label. LPA observed Resident #1 all PRN medication include Allei-Tec 10mg, B12 Vitnamin 1000mcg, Calcium
8
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14
600mg and Spectra-Vite 365 tab.
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14
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07/13/2017
Section Cited
87406
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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:Patricia Magana
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2017


LIC809 (FAS) - (06/04)
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