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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602371
Report Date: 06/21/2024
Date Signed: 06/21/2024 04:13:16 PM


Document Has Been Signed on 06/21/2024 04:13 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:GRANDRIDGE RESIDENTIAL CAREFACILITY NUMBER:
198602371
ADMINISTRATOR:PALOMINO, BORISFACILITY TYPE:
740
ADDRESS:2016 S GRANDRIDGE AVETELEPHONE:
(323) 353-1167
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY:6CENSUS: 6DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Sara Aguiire, Caregiver TIME COMPLETED:
04:23 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Sara Aguirre Caregiver and explained the reason for the visit. Administrator Boris Palomino gave authorization for Sara Aguirre to sign report.

The facility is licensed to serve 6 non-ambulatory residents aged 60 and over, with a hospice waiver approved for 4. Facility is a single home located in a residential area and consist of 4 bedrooms, 3 bathrooms, living room, dining room, kitchen, and detached garage. Currently there is two (2) hospice residents.

LPA Lopez toured the facility with Sara Aguirre and observed the following:
Facility is clean and in good repair inside and outside. Living room has sufficient seating space and activity area was observed. Kitchen was observed clean, knives were stored in a cabinet with a magnet lock. Refrigerator/pantry was observed with sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Cleaning supplies were observed locked in the laundry. Dining/family room was observed with sufficient seating area. Each residents' room was observed with the required furniture, bedding, and sufficient lighting. A locked closet was observed with medications and additional linens. Bathrooms (3) were observed in working condition and water temperature was tested between 114.0 – 114.4 degrees F., which is within the required 105-120 degrees F. Backyard has a shaded seating area and no pools or bodies of water were observed. Smoke/Carbon Monoxide detectors were tested and are in working condition. 2 window screens in front of the home are in need of minor repair, not immediate health or safety hazard.

LPA Lopez reviewed medication and files for 5 residents and reviewed 4 staff files. R1 has had change of condition in last 8 days and needs updated needs and services plan. Last one is dated 01/19/2024. Administrator certificate was observed for Boris Palomino #6031265740 exp. date: 6/15/24. Renewal mailed out certified mail on 06/01/2024 Disaster plan was reviewed; last evacuation drill was conducted is June 1, 2024. Emergency plan needs updating. LPA interviewed 3 staff and 2 residents.

No deficiencies were noted during this visit. Technical advisories issued.
Exit interview was conducted with Amanda and Boris Palomino and a copy of this report was provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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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