198202296-9-30-2023-11-AS-FSHY-CW6KYQ-20230930081930

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198202296
Report Date: 06/15/2023
Date Signed: 09/30/2023 08:20:07 AM

Document Has Been Signed on 09/30/2023 08:20 AM - 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:	ELEANOR'S RESIDENTIAL HOME		FACILITY NUMBER:	198202296
ADMINISTRATOR:	BINMOELLER, SARA R.C.		FACILITY TYPE:	740
ADDRESS:	4926 SHENANDOAH AVE		TELEPHONE:	(310) 216-9422
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90056
CAPACITY:	6	CENSUS:	DATE:	06/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Sara Binmoeller		TIME COMPLETED:	12:05 PM

NARRATIVE

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Licensing Program Analyst (LPA) Felisa Shirley made an unannounced annual visit using the CARE tools. LPA met with administrator, Sara Binmoeller and explained the purpose of today’s visit. There are currently 5 residents in the facility.

LPA and Administrator Sara toured the facility. The home consists of 7 bedrooms and 4 bathrooms. On the first floor there are 3 resident bedrooms, 3 bathrooms (2 full baths), living room, sitting room, dining room, kitchen, laundry room, and attached garage. On the second floor there are 4 bedrooms, and bathroom.

Resident bedrooms and bathrooms were checked. Resident bedrooms had the required furniture, including beds, nightstands, dressers, and chairs. There is ample closet space and lighting. Each bed had the necessary linens including mattress cover, fitted sheets, blanket, comforter and pillow. There were additional linens and towels in the closets. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat and chair was in place. Water temperature delivered at 118.9 degrees Fahrenheit.

All appliances were in good working condition. LPA observed a 3-day supply of perishable foods and a 14-day supply of nonperishable foods. In the garage there are 2 additional refrigerators and a freezer as well as shelves full of canned goods. There is a large supply of water. All cutleries were in good condition. LPA oberved that Knives were not locked in a cabinet in the kitchen.

LPA and Administrator toured the outside grounds as well. There is ample seating and a table with an umbrella. Walkways around the home were clear of hazards. There was a fountain in the backyard inaccessible to residents. There are no security bars or weapons on the premises.

Con'd 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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: ELEANOR'S RESIDENTIAL HOME	FACILITY NUMBER: 198202296
	VISIT DATE: 06/15/2023

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A deficiency is being cited based on LPA observation in accordance with the California Code of Regulations, Title 22. A violation regarding knives in an unlocked drawer accessible to residents warrants an immediate citation and is hereby cited. Administrator moved knives from the drawer immediately and locked them in a cabinet.

Exit interview conducted and a copy of report and appeals right were discussed and was given to the administrator.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/30/2023 08:20 AM - It Cannot Be Edited

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: ELEANOR'S RESIDENTIAL HOME	FACILITY NUMBER: 198202296
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not ensure safety by not locking knives up which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/29/2023
	Plan of Correction
1 2 3 4	Licensee will put a lock on the drawer.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

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