198201597-7-10-2023-11-AS-EBRN-B8W23S-20190129160249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198201597
Report Date: 01/29/2019
Date Signed: 07/10/2023 01:22:43 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 DR #100
MONTERY 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:	01/29/2019
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:38 PM
MET WITH:	ANA MARIA RAMOS, Administrator		TIME COMPLETED:	04:00 PM

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Licensing Program Analyst (LPA) Erik Brown conducted an unannounced visit to Ana's Elderly Care Home. The purpose of today’s visit was to conduct the annual inspection. LPA met with Administrator, Ana Ramos. Facility is licensed for 6 non-ambulatory residents and 1 bedridden resident. The facility has an approved hospice waiver for 1 resident. The facility currently has 1 ambulatory resident. 0 of the residents are diagnosed with Dementia or are receiving home health or hospice services. The facility does not handle any of the residents’ money.

LPA Brown toured the physical plant and checked food service. The facility conducted a fire drill on December 3rd when the fire department came out and did an inspection. The home consists of 3 resident bedrooms, 2 staff bedrooms, 4 bathrooms, including 1 staff bathroom, living room, dining room, and two kitchens. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets worked properly, water faucets worked properly in 3 out of 4 bathrooms, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature properly measured between 105- and 120-degrees Fahrenheit. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. All doors have auditory alarms.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

SUPERVISORS NAME: Myriam Luga
LICENSING EVALUATOR NAME: Erik Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2019

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
MONTERY PARK, CA 91754

FACILITY NAME: ANA'S ELDERLY CARE HOME	FACILITY NUMBER: 198201597
	VISIT DATE: 01/29/2019

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Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview conducted and a copy of this report was given to Administrator, Ana Ramos.

No deficiencies cited during this visit.

Advisor Note: Auditory alarms were not operable; however, facility does not have any residents with Dementia. Advised Administrator, Ana Ramos to repair auditory alarms.

Advisory Note: Water pressure and sink drain not working properly. Advised Administrator Ana Ramos to have plumber come out and repair drain and faucet. Also advised Administrator, Ana Ramos to send over an invoice of the repairs.

Advisor Note: Advised Administrator, Ana Ramos to remove alcoholic beverages from cabinet or place a lock on the door. Administrator chose to lock it up in storage room.

SUPERVISORS NAME: Myriam Luga
LICENSING EVALUATOR NAME: Erik Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2019

LIC809 (FAS) - (06/04)

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