198201597-9-8-2023-11-AS-PBUR-CVH25J-20230908170537

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198201597
Report Date: 09/08/2023
Date Signed: 09/08/2023 05:06:01 PM

Document Has Been Signed on 09/08/2023 05:06 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:	09/08/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	07:33 AM
MET WITH:	Ana Ramos		TIME COMPLETED:	11:55 AM

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 Annual/Random 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/Administrator Ana Ramos and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan Report and Infection Control Report. There is currently one (1), resident in placement. The facility's annual fees are current. The following Domains will be observed and reviewed: Infection Control, Operational Requirements, Physical Plant and Environmental Safety, Staffing, Personnel Records-Staff Training, Residents Records-Incident Reports, Resident Rights-Information, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness, and Resident with Special Health Needs,. "LPA Bunker 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: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANA'S ELDERLY CARE HOME	FACILITY NUMBER: 198201597
	VISIT DATE: 09/08/2023

NARRATIVE

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Continued LIC809-C page #2

During the tour, LPA observed the facility’s infection control practices. LPA observed sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of PPE was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed. LPA observed staff and residents wearing a face covering and social distancing.

Documents were posted as mandated on the bulletin board wall in the living room. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. The first aid kit is fully stocked with a manual, the hot water temperature was measured at 115 degrees Fahrenheit, the telephones are working, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, medications were centrally stored and properly locked in the kitchen file cabinet and records are current, ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted on July 26, 2023. No firearms on the premises, the client's bedroom windows had no sliding window lock with thumbscrew, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards. The Licensee/Administrator Ms. Ramos states staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited. LPA Bunker provided Licensee/Administrator Ms. Ramos with copies of the LIC809, LIC809-C, LIC858, and LIC859 documents.

Exit interview conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

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