198602010-8-31-2022-28-AS-LMOA-CHTTXN-20220831150727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602010
Report Date: 08/31/2022
Date Signed: 08/31/2022 03:07:37 PM

Document Has Been Signed on 08/31/2022 03:07 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	LAKEWOOD PALACE HC		FACILITY NUMBER:	198602010
ADMINISTRATOR:	ELVIRA C. DAVID		FACILITY TYPE:	740
ADDRESS:	12440 EAST 207TH ST.		TELEPHONE:	(562) 924-3132
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90715
CAPACITY:	6	CENSUS: 5	DATE:	08/31/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Elvira David - Administrator		TIME COMPLETED:	03:20 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 at the facility with focus on the infection control domain, medication and food review. LPA Mora met Administrator Elvira David and explained the reason for the visit. The facility is licensed to serve 6 residents over the age of 60, four non-ambulatory and approved for two hospice residents. The facility is operating within the scope of its license. The facility is located in a residential area. A tour of the single-story facility included: kitchen, dining area, living room, 3 resident bedrooms, 3 bathrooms, laundry room, backyard, and attached garage. LPA and Elvira David toured the facility and the following was observed: sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen and garage. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in all 3 bathrooms and measured at 15.6 degrees F, 105.8 degrees F, and 105.4 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 each resident bedroom’s closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. Carbon monoxides were observed in the kitchen and living room and are properly operating. Fire extinguishers were observed in the kitchen and living room which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are kept locked in a kitchen cabinet. Cleaning supplies and toxins are kept locked in a laundry room cabinet. First Aid kit was fully stocked with current manual and it is kept in the medication closet. The front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. There are no bodies of water at the facility. Passageways and exits are free of obstruction. (CONTINUED TO LIC 809C)

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LAKEWOOD PALACE HC	FACILITY NUMBER: 198602010
	VISIT DATE: 08/31/2022

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
26
27
28
29
30
31
32

Residents medication are centrally stored in a locked closet in the dining area. Residents and staff files are centrally stored in a dining area cabinet. LPA reviewed medication for all 5 of the residents and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 5 residents and 3 staff. No issues were found with the files. LPA observed administrator certificate for Elvira David – 6009328740 with an expiration date of 05/06/2024.

Facility is following COVID 19 recommendations regarding screening visitors, staff, and residents. Signs are posted throughout the facility, and hand-washing signs were observed in bathroom. Sufficient hand soap, hand sanitizer, and paper towels were observed. Supply of 30-day Personal Protective Equipment (PPE) was observed in the garage.

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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2