198603457-5-26-2021-28-AS-LMOA-C3DU79-20210526151935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603457
Report Date: 05/26/2021
Date Signed: 05/26/2021 03:19:45 PM

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:	AYANNA HOME CARE		FACILITY NUMBER:	198603457
ADMINISTRATOR:	MATE, KELVIN		FACILITY TYPE:	740
ADDRESS:	5602 WHITEWOOD AVE		TELEPHONE:	(909) 351-6012
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90712
CAPACITY:	6	CENSUS: 4	DATE:	05/26/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Kelvin Mate, Applicant		TIME COMPLETED:	03:30 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 Analysts (LPAs) Luis Mora and Mary Flores conducted a pre-licensing visit. Today's pre-licensing visit was conducted with applicants Kelvin Mate Applicant, Cielo Mate - House Manager, and Jason Dy Facility's consutant. LPA Luis Mora reviewed the Component III PowerPoint with applicants Kelvin Mate and Cielo Mate. The facility is currently licensed as Aura - 198602543. This is a change of ownership and there are currently 4 residents in the facility. The fire clearance has been approved for 6 non-ambulatory residents and 0 bedridden residents. LPAs observed the following during the pre-licensing tour: There are 7 exit doors in total and 6 exit doors each had an operating auditory device. The auditory device on the exit door #7 on the right side of the house was not working. Smoke detectors were observed in common areas and in each resident bedroom. There is 1 carbon monoxide detector and it is located in the kitchen. Cleaning solutions and chemicals were observed in restroom #1 and backyard and were not locked. The garage was observed to only be used for storage. The garage has an extra refrigerator with extra food. Medications were located in a cabinet in the kitchen and were not locked. PRN medications were observed in medication cabinet without a prescriptions. There is an incomplete first aid kit which is missing the tweezers and current manual. Windows and doors are in good condition and there were no obstructions near doors. There are also no security bars on the windows. There are 4 bedrooms which consist of 2 private rooms and 2 shared rooms for residents. Beds did not have all of the required linen/supplies which are mattress pads, fitted sheet, flat, and bedspreads. Bedroom #1 the closet was occupied with pampers, bedding pads, and oxygen tanks, and had no space for the residents' clothing. Bedroom #2 is currently vacant, however the closet in this room is being used to store a caregivers personal clothing and belongings. Bedroom #3 is one of the shared rooms, but only 1 bed was observed in the room. The home has 2 bathrooms. One bathroom near bedroom #1 and #2 is designated for residents. This bathroom is missing paper towels. The bathroom has the required grab bars in the shower and near the toilet along with the required skid mat. The other bathroom near bedroom #3 and #4 is designated for staff only. This bathroom has sufficient hygiene products, but it is missing paper towels.. Continued to LIC 809C.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AYANNA HOME CARE	FACILITY NUMBER: 198603457
	VISIT DATE: 05/26/2021

NARRATIVE

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There is sufficient lighting throughout the home including common areas and resident bedrooms. The hot water temperature in bathroom #1 was at 125.2 degrees F* and bathroom #2 was at 123.2 degrees F*, which is not within the required 105 - 120 degrees. All appliances in the kitchen were observed to be clean and operational. Foods were observed for 2 days of perishable and 7 days of non-perishable. The sharp knives are located in a locked closet near the kitchen. The washer and dryer are located in a small closet inside the house. The backyard did not have a shaded patio area and was not properly clean. The home does not have a pool or any large bodies of water. Resident files were reviewed since the facility is currently operating. Files reviewed were not up to date and missing information was found. The files reviewed indicated that there are currently 2 bedridden residents in the facility which does not match the information on the LIC 200, fire clearance, and facility sketch.

The following must be address within the next 7 days and submit proof to the department:

Applicant corrected the water temperature by adjusting the heater temperature and will maintain a log for 7 days which will be submitted to the department.
Medication will be kept locked.
Cleaning supplies and chemicals will be kept locked.
Applicant will provide all bedding items for each resident.
Applicant will remove clothing from closet, items in back yard, and ensure backyard is clean.
Applicant will provide a shaded area in the backyard.
Applicant will ensure all residents have all the required assessments and documents in resident files.
Applicant will ensure that there is a tweezer and current first aid manual in the first aid kit.
Applicant will ensure all medications and PRN medications are prescribed by a physician.
The LIC 200 and the fire clearance indicate zero bedridden and 6 non-ambulatory.
Two facility sketches were submitted - one indicates 1 bedridden and 5 non ambulatory and the other indicates 6 non-ambulatory.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AYANNA HOME CARE	FACILITY NUMBER: 198603457
	VISIT DATE: 05/26/2021

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	Applicant will verify with Sacramento regarding serving residents with Dementia. Per California Code of Regulations Tittle 22, the home does not meet the minimum physical plant requirements. Exit interview was conducted with Kelvin Mate and a copy of report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

LIC809 (FAS) - (06/04)

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