<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602010
Report Date: 07/05/2024
Date Signed: 07/05/2024 05:22:59 PM

Document Has Been Signed on 07/05/2024 05:22 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LAKEWOOD PALACE HCFACILITY NUMBER:
198602010
ADMINISTRATOR/
DIRECTOR:		ELVIRA C. DAVIDFACILITY TYPE:
740
ADDRESS:12440 EAST 207TH ST.TELEPHONE:
(562) 924-3132
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 6CENSUS: 6DATE:
07/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:57 PM
MET WITH:Administrator Elvira David TIME VISIT/
INSPECTION COMPLETED:
05:30 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 Analysts (LPA) Tyler Reyes conducted an unannounced annual visit at the facility using the CARE Tool. LPA Reyes met with Elvira David (Administrator) and explained the reason for the visit. The facility is licensed to serve 6 residents over the age of 60, four non-ambulatory and approved for two hospice waivers. The facility is operating within the scope of its license.

A tour of the single-story facility included: kitchen, dining area, living room, 3 resident bedrooms, 3 bathrooms, laundry room, backyard, and attached garage. LPA and Administrator Elvira David 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 bathroom and measured at 116.1 degrees F which is within the required 105 - 120 degrees F. The bathroom is 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. Smoke detectors were observed in each room and throughout the facility and are properly operating. Carbon monoxides were observed in the kitchen and family room and are properly operating. Fire extinguishers were observed in the kitchen and family room which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are kept locked in a kitchen cabinet. Cleaning supplies and toxins are kept locked in a laundry room cabinet. First Aid kit was fully stocked with current manual and it is kept in the medication closet. 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 809-C)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 07/05/2024 05:22 PM - It Cannot Be Edited


Created By: Tyler Reyes On 07/05/2024 at 03:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LAKEWOOD PALACE HC
FACILITY NUMBER: 198602010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(2)
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.

This requirement is not met as evidenced by: Per record review and interview with Administrator Elvira David she did not notify the licensing agency and the local health officer when appropriate. Administrator Elvira David stated there was "not enough time to noftiy due to the outbreak the licensing agency and the local health officer".
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety risk to persons in care.
POC Due Date: 07/05/2024
Plan of Correction
1
2
3
4
Administrtator Elvira David will provide proof of contact with Long Term Care Ombudsman, LA Dept of Public Health, and CCL by POC Due Date.

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:Fernando Fierros
LICENSING EVALUATOR NAME:Tyler Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LAKEWOOD PALACE HC
FACILITY NUMBER: 198602010
VISIT DATE: 07/05/2024
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
26
27
28
29
30
31
32
Residents medication are centrally stored in a locked closet in the dining area. Residents and staff files are centrally stored in a dining area cabinet. LPA reviewed medication for all 6 of the residents and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 6 residents and 3 staff. No issues were found with the files. LPA interviewed 2 staff and no residents due to outbreak.

Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on the LIC809-D page.

Exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3