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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602010
Report Date: 11/09/2021
Date Signed: 11/09/2021 04:46:56 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/09/2021 04:46 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:LAKEWOOD PALACE HCFACILITY NUMBER:
198602010
ADMINISTRATOR:ELVIRA C. DAVIDFACILITY TYPE:
740
ADDRESS:12440 EAST 207TH ST.TELEPHONE:
(562) 924-3132
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 6CENSUS: 6DATE:
11/09/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Elvira David TIME COMPLETED:
05:00 PM
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Licensing Program Analyst(LPA) Nicol Wesley conducted an unannounced Required 1 year (annual continuation) year inspection at the facility and met with Administrator Elvira David and explained the purpose for todays visit. Prior to the visit LPA Wesley conducted a risk assessment for on-site inspections. The facility phone number is 562 924 3132.

The facility is a two story home that consist of (5) five bedrooms(2 for staff), (4) bathrooms(1 for staff). kitchen, laundry area, living room, dining room. The first level consists of (3) resident bedrooms and (3) resident bathrooms, family room, kitchen, TV area, and laundry room, back yard with outside shaded area, and a Garage. The second level(upstairs) is designated for staff use only, which consists of (2) bedrooms and (1) one bathroom. The facility is licensed for 6 residents age 60 and above, in which 4 can be non ambulatory, and there is a Hospice waiver for a total of 2 residents. A Pre screening area with PPE supplies was observed upon entry into the facility. LPAs observed the supply of food. Resident medications, and medication logs were reviewed.

LPA toured the entire physical plant and observed: Resident Bedroom #1(bathroom #1), Bedroom #2(bathroom #2), Bedroom #3, and Bathroom #3 to have all required furniture, and the bathrooms and showers are operable. During the visit the Infection control domain was used and the following areas were observed/inspected: The facility had all postings at the front entrance, bathrooms, throughout the facility, and back exit door(family room). Hand sanitizing gel and masks were located at the entry of each room.

The smoke detectors/carbon monoxide detector are operable. There are a total of 5 fire extinguishers(kitchen, family room, patio, garage, and 2nd flood hallway). The water temperature was tested and measured 113.7 degrees F. The final mitigation report was received on 07/26/21. Administrators certificate for Elvira C. David #6009328740 expires on 05/16/2022. There are no deficiencies cited during todays visit. Exit interview conducted.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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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