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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603457
Report Date: 08/27/2024
Date Signed: 08/27/2024 03:33:35 PM


Document Has Been Signed on 08/27/2024 03:33 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:AYANNA HOME CAREFACILITY NUMBER:
198603457
ADMINISTRATOR:MATE, KELVINFACILITY TYPE:
740
ADDRESS:5602 WHITEWOOD AVETELEPHONE:
(909) 351-6012
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY:6CENSUS: 4DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Elba Rodriguez - AdministratorTIME COMPLETED:
03:48 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with the Administrator Elba Rodriguez 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.

A tour of the single-story facility included: 4 resident bedrooms, 2 bathrooms, living room, kitchen, open area, 2 caregiver rooms, backyard, and attached garage. LPA and Elba Rodriguez 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 118.3 degrees F and 116.6 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. Residents medication are centrally stored in a locked kitchen cabinet. LPA reviewed staff and resident files. LPA reviewed residents medication.

Due to time constraint, the LPA will return at different date to complete the annual inspection. Exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
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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