198601969-5-27-2023-28-AS-LMOA-CS8RCM-20230527125434

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601969
Report Date: 05/27/2023
Date Signed: 05/27/2023 12:54:37 PM

Document Has Been Signed on 05/27/2023 12:54 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	OAK GARDEN		FACILITY NUMBER:	198601969
ADMINISTRATOR:	LUIS EFREN AGUILAR		FACILITY TYPE:	740
ADDRESS:	246 E. NEWMAN AVENUE		TELEPHONE:	(626) 358-8230
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91006
CAPACITY:	6	CENSUS: 5	DATE:	05/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Laura Aguilar - Assistant Administrator		TIME COMPLETED:	01:10 PM

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) Luis Mora conducted an unannounced annual visit using the CARE Tool. LPA met with Laura Aguilar (Assistant Administrator) and explained the reason for the visit. The facility is licensed to serve 6 non-ambulatory residents in the age range of 60 and over. The facility has a hospice care waiver for 6 residents. The facility is operating within the scope of its license. A tour of the single-story facility included: living room, kitchen, dining room, 4 resident bedrooms, 2 bathrooms, front porch, backyard, and attached garage. LPA and Laura Aguilar toured the facility and the following was observed: the front porch and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. Auditory devices were seen on exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in both bathrooms and measured at 112.1 degrees F and 115.1 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility, and were properly operating. There is a carbon monoxide in the dining area and was properly operating. There is one fire extinguisher located in the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps, cleaning supplies and toxins are kept locked under the kitchen sink and are inaccessible to residents. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen and garage freezer. First Aid kit was fully stocked with current manual and it is kept locked in the medication cabinet. Residents and staff files are centrally stored in the medication cabinet. Residents medication are centrally stored in a locked kitchen cabinet. (Continued to LIC 809-C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OAK GARDEN	FACILITY NUMBER: 198601969
	VISIT DATE: 05/27/2023

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LPA reviewed medication for all 5 residents and observed that medications are documented properly and given as prescribed. LPA reviewed all 5 resident files and 5 staff files. LPA observed administrator certificate for Luis Aguilar – 6020261740 with an expiration date of 09/23/2024. LPA interviewed 2 staff and attempted to interview all 5 residents.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2023

LIC809 (FAS) - (06/04)

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