198603457-9-1-2022-28-AS-LMOA-CHUTQH-20220901145559

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603457
Report Date: 09/01/2022
Date Signed: 09/01/2022 02:56:04 PM

Document Has Been Signed on 09/01/2022 02:56 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:	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:	09/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:			TIME COMPLETED:	03:10 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 at the facility with focus on the infection control domain, medication and food review. LPA Mora met Administrator Kelvin Mate and explained the reason for the visit. The facility is licensed to serve 6 non-ambulatory residents only over the age of 60 and approved for 3 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: 4 resident bedrooms, 2 bathrooms, living room, kitchen, rest area, backyard, and attached garage. LPA and Kelvin Mate 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 2 bathrooms and measured at 17.6 degrees F and 116.8 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 hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. A carbon monoxide was observed in the kitchen and it is properly operating. Fire extinguishers were observed in the kitchen, living room, and hallway which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps and cleaning supplies are kept locked in a kitchen closet. First Aid kit was fully stocked with current manual and it is kept in the medication cabinet. 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: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

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: 09/01/2022

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Residents medication are centrally stored in a locked kitchen cabinet. Residents and staff files are centrally stored in a kitchen cabinet. LPA reviewed medication for 3 of the residents and observed that medications are documented properly and given as prescribed. Hospice agency discontinued all medication for 1 of the residents. LPA reviewed files for all 4 residents and 1 staff. No deficiencies were found with the files. LPA observed administrator certificate for Kelvin Mate – 6054957740 with an expiration date of 01/07/2024.

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: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC809 (FAS) - (06/04)

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