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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603120
Report Date: 08/09/2022
Date Signed: 08/09/2022 01:09:00 PM

Document Has Been Signed on 08/09/2022 01:09 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:FOREVER YOUNG AGAINFACILITY NUMBER:
198603120
ADMINISTRATOR:LAURETA, MARTINIANAFACILITY TYPE:
740
ADDRESS:4317 W COUNTRY CLUB BLVDTELEPHONE:
(310) 779-4496
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 4CENSUS: 3DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Martiniana Laureta, AdministratorTIME COMPLETED:
01:17 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Annual Required / Infection Control Visit to the above facility. LPA was met by Martiniana Laureta, Administrator and the purpose of today’s visit was explained. Administrator certificate expires 3/27/2023 Last fire drill was 06/02/22

There are currently (3) residents in the facility. The facility consists of: 2 shared resident bedrooms, 2 bathrooms (1 staff bathroom), kitchen/ dining, living room and yard area. Physical plant inside and outside is in good repair.

LPA and Administrator Laureta toured the entire facility inside and out. Documents are posted as mandated. Resident bedrooms contain the mandated furniture. The bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector complied and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents in a locked file cabinet. Food supply was adequate for 2-day perishable and 7-day non-perishable. Hot water temperature ranged from 111.8 - 112.2 degrees Fahrenheit. Linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to clients, exits, walkways and/or passageways, are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, LPA was screened at entrance, visitors are logged, and temperature checked, sanitizer/soap located throughout the facility and additional sanitation supplies are stored in the facility. LPA observed staff wearing mask. Resident vacant room in adjacent home will be converted to isolation room (if needed) and required postings placed throughout the facility. The residents temperature's are checked and logged twice a day as is facility staff. PPE's are enough for 30 days. 1 of 6 staff did not have background clearance or associated to facility which is health and safety issue.

According to the California Code of Regulations, LPA did observe deficiencies, citation and civil penalties were issued at this time. Exit interview was completed with Martiniana Laureta, Administrator and copy of report provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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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Document Has Been Signed on 08/09/2022 01:09 PM - It Cannot Be Edited


Created By: Alberto Lopez On 08/09/2022 at 12:37 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: FOREVER YOUNG AGAIN
FACILITY NUMBER: 198603120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance(e)

All individuals subject to a criminal record review pursuant to Health and safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the department.

This requirement is not met by evidence by:



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 persons did not have background cleareance and was not associated to facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
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Licensee will get background clearence for one staff and associate staff to facility before she returns to work. Licensee will send LPA LIC 9163 and copy if ID to LPA as well as evidence that staff is cleared and associated to facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022


LIC809 (FAS) - (06/04)
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