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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002065
Report Date: 07/20/2022
Date Signed: 07/25/2022 02:56:29 PM


Document Has Been Signed on 07/25/2022 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:LAS PALMAS HOME CAREFACILITY NUMBER:
306002065
ADMINISTRATOR:MARTHA SERNAFACILITY TYPE:
740
ADDRESS:116 W. LAS PALMAS DR.TELEPHONE:
(714) 773-0055
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:6CENSUS: 5DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Veronica and Lourdes SernaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Michelle Reed arrived at the facility to conduct a Required 1 Year inspection. The inspection focused primarily on Infection Control. LPA was greeted by Staff Lourdes Serna. Lourdes confirmed that there were no covid positive staff or residents at this time. Ms. Serna contacted Veronica Serna via telephone and she arrived at approximately 3:30pm. LPA's temperature was not taken prior to entry. There was a sanitation station and a sign in sheet at the front door. Staff were observed not wearing masks upon entry. LPA reminded that masks must be worn and they were worn throughout the visit. The facility is licensed for 6 non-ambulatory residents of which 1 may be bedridden. The facility also has a Hospice waiver for 6 residents. Currently there are 5 residents of which 2 are receiving Hospice services.

At approximately 3:15pm, LPA Reed conducted a tour of the physical plant along with Staff Lourdes Serna. Resident’s were observed resting in their rooms and watching tv. Resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. Soap, paper towels and toilet paper were present. Resident bath towels and personal hygiene supplies were adequately stocked. LPA tested the hot water temperature in the resident bathrooms and the temperature measured at 119 degrees F.

LPA inspected the kitchen. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The freezer is not operable. There is a freezer in the garage that is being used. The fire extinguishers were fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Two of the detectors in the hallway need batteries. Medications, toxins and sharps were locked and inaccessible to residents/clients.


SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LAS PALMAS HOME CARE
FACILITY NUMBER: 306002065
VISIT DATE: 07/20/2022
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LPA toured the outside grounds. There is a swimming pool present. It meets Title 22 guidelines for bodies of water. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the exit gate had a self-closing latch.

No resident or staff files were reviewed at the time of this visit. LPA noted Covid precaution signs posted outside and inside the facility. There was not a 30 day supply of PPE present. Licensee also had the Infection Control Plan available for review and will send a copy to her assigned analyst.

LPA reviewed Assembly Bill 665. This bill requires residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use.

An exit interview was conducted with Veronica Serna and a copy of this report and Advisory Notes were issued at the time of this visit. See LIC9102's.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC809 (FAS) - (06/04)
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