198201597-9-13-2024-11-AS-HENZ-D93RUC-20240913131942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198201597
Report Date: 09/13/2024
Date Signed: 09/13/2024 01:20:04 PM

Document Has Been Signed on 09/13/2024 01:20 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

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:	09/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:03 AM
MET WITH:	Administrator Ana Ramos		TIME COMPLETED:	01:30 PM

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On 09/13/2024 at around 8:00 am, Licensing Program Analyst (LPA) Hollie Enriquez conducted an unannounced required annual inspection to the above facility. LPA was initially met by Caregiver Maria Gonzalez and later joined by Administrator Ana Ramos. LPA explained the purpose of today’s visit. Facility is licensed to serve 6 non- ambulatory residents aged 60 and above of which one (1) bedridden resident may be in bedroom #B. The Facility has an approved hospice waiver for 1 resident. None of the residents are diagnosed with dementia or hospice at this time. The facility does not handle any of the residents’ money. The facility license fees are paid to current.

There is currently one (1) resident in care at the facility. The Culver City Fire Department conducted the most recent fire drill and inspection on 07/18/24. Caregiver reported that the most recent fire and earthquake drills conducted with staff and residents only was on 09/13/24. Fire extinguishers are fully charged and last serviced 08/08/2024.

The home is a single-story home in a residential neighborhood consisting of: five (5) bedrooms, four (4) bathroom, office area, den, living room, two (2) kitchens and a laundry room, activity areas and a detached garage. There is a shaded patio with table, umbrella and chairs surrounded a maintained garden area in the backyard.

Continued on 809C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Hollie Enriquez	TELEPHONE: (916) 908-8866
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ANA'S ELDERLY CARE HOME	FACILITY NUMBER: 198201597
	VISIT DATE: 09/13/2024

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Administrator and Caregiver toured LPA through the interior and exterior facility grounds. The Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. There is a videoconferencing device dedicated for resident use in the activity area by kitchen #2.

Sole resident in care resides in bedroom #B with private full bathroom. Water temperature of bathroom was measured at 105.2 degrees Fahrenheit.

Main kitchen was checked and observed to be within Title 22 regulations. Three (3) days perishable and one (1) week non-perishable food supply was checked. Emergency water and food supplies stocked. 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 with manual was fully stocked and complete. 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.

LPA reviewed two (2) out of two (2) personnel files and one (1) out of one (1) resident files and observed records to be complete and compliant with Title 22 regulations. LPA reviewed resident medications and records and observed all to be labeled and documented according to regulations.

No deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted and a copy of this report was left with Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Hollie Enriquez	TELEPHONE: (916) 908-8866
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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