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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601775
Report Date: 07/03/2024
Date Signed: 07/03/2024 01:52:02 PM

Document Has Been Signed on 07/03/2024 01:52 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:PALM GROVE RESIDENTIAL CAREFACILITY NUMBER:
198601775
ADMINISTRATOR/
DIRECTOR:		TOWANNA CARTERFACILITY TYPE:
735
ADDRESS:2914 PALM GROVE AVE.TELEPHONE:
(323) 294-0434
CITY:LOS ANGELESSTATE: CAZIP CODE:
90016
CAPACITY: 6CENSUS: 1DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:21 AM
MET WITH:Towanna CarterTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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On 07/03/24 Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual inspection visit to the above facility using the CARE tool. LPA was met by Towanna Carter, Director, and the purpose of today’s visit was explained. The facility is licensed to serve six (6) clients age range 18 through 59, ambulatory only. Currently there is (1) client in the facility.

The facility is a two-story structure located in a residential neighborhood. It consists of three (3) bedrooms, two (2) bathrooms, dining room, living room, kitchen, and staff office with an outdoor shaded area.

LPA Gonzalez and Towanna Carter toured the physical plant. There were no bodies of water or obstructions on the premises. Exits/ Walkways around the facility were free of debris and hazards. Client room(s) were inspected. Bedrooms had the required furniture and in good condition, adequate lighting was observed, and sufficient closet/drawer space to accommodate the client comfortably. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were clean and operational and found to be within Title 22 regulations. The water temperature properly measured between 105.0 F and 120.0 F. A comfortable temperature was maintained in the facility.

The kitchen was inspected and there is sufficient perishable and non-perishable food supply and maintained adequately. Sharps, toxins, cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. LPA reviewed the Client’s Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit. A landline was observed. Smoke detectors and carbon monoxide were tested and are working properly. Fire extinguishers were fully charged. A stocked First Aid kit along with manual was available.

Continued on LIC809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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: PALM GROVE RESIDENTIAL CARE
FACILITY NUMBER: 198601775
VISIT DATE: 07/03/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. There are sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted.

During this inspection LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted, and a copy of the report was given to Towanna Carter, Director.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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