331881455-9-4-2024-18-AS-SJEN-D8SV42-20240904160536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881455
Report Date: 09/04/2024
Date Signed: 09/04/2024 04:05:44 PM

Document Has Been Signed on 09/04/2024 04:05 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	LUNA SENIOR LIVING		FACILITY NUMBER:	331881455
ADMINISTRATOR:	MAMYAN, NARINE		FACILITY TYPE:	740
ADDRESS:	1361 E LUNA WAY		TELEPHONE:	(818) 568-6812
CITY:	PALM SPRINGS	STATE: CA	ZIP CODE:	92262
CAPACITY:	6	CENSUS: 3	DATE:	09/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Naira Alikhanyan, caregiver		TIME COMPLETED:	04:15 PM

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Licensing Program Analyst (LPA), Seo Jeon, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was greeted and allowed to enter the facility to conduct the inspection. LPA met with Naira Alikhanyan, caregiver, and she was notified of the purpose for the visit.

The facility is a one story home with (4) bedrooms and (3) bathrooms with attached garage. The facility does not have swimming pool or any body of water. No fire arms are kept at the facility. The facility is designated as a residential facility for the elderly serving ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents, and observed the following:

The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA observed several cleaning solutions in the kitchen cabinet under the sink which is not equipped with locking device. Deficiency is cited.

Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke and carbon monoxide detectors were operational, and the hot water temperature was 117 degrees F.

LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Continued on LIC809-C.....

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LUNA SENIOR LIVING	FACILITY NUMBER: 331881455
	VISIT DATE: 09/04/2024

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Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff schedule showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate.

LPA reviewed three (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Three (3) client files were reviewed and possessed all required paperwork.

LPA reviewed medication and medication log. Residents' medications are being dispensed according to physician's orders.

LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility performs quarterly fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items.

Based on the LPA's observation during this visit today in the areas reviewed, one (1) deficiency is being cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where a copy of this report, LIC809-D and appeals right were provided to Naira Alikhanyan, caregiver.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/04/2024 04:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LUNA SENIOR LIVING	FACILITY NUMBER: 331881455
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of one which posed a potential health, safety or personal rights risk to persons in care. LPA observed dishwasher cleaning packets are stored in kitchen cabinet under sink without locking device.
	POC Due Date: 09/04/2024
	Plan of Correction
1 2 3 4	Staff immediately removed the dishwasher cleaning packets and stored in a locked cabinet.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

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