198603120-8-28-2023-28-AS-AGOZ-CV5S6C-20230828133542

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603120
Report Date: 08/28/2023
Date Signed: 08/28/2023 03:55:17 PM

Document Has Been Signed on 08/28/2023 03:55 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	FOREVER YOUNG AGAIN		FACILITY NUMBER:	198603120
ADMINISTRATOR:	LAURETA, MARTINIANA		FACILITY TYPE:	740
ADDRESS:	4317 COUNTRY CLUB DRIVE		TELEPHONE:	(310) 779-4496
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90019
CAPACITY: 4		CENSUS: 4	DATE:	08/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Martiniana Laureta		TIME COMPLETED:	01:30 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 Analyst (LPA) Alma Gonzalez conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Gonzalez met with Administrator Martiniana Laureta and explained the purpose for the visit. The facility is licensed to serve 4 non-ambulatory elderly residents age 59 and over. Approved for (4) Non Ambulatory of which 1 may be bedridden. Approved Hospice Waiver for 2. Currently, there are five (4) residents placement. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs (SHN). During the visit LPA observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. There is a visitor sign-in/ screening station located in the main entrance. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Per Facility Administrator five (4) residents have COVID-19 vaccines including boosters. Per Facility Administrator all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements. Refer to LIC 809C for continuation of report

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FOREVER YOUNG AGAIN	FACILITY NUMBER: 198603120
	VISIT DATE: 08/28/2023

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

Operational Requirements: Fire Drills are conducted every three months, the last fire drill was conducted on 6/1/23. Emergency Disaster/ Earthquake Drills are also conducted every three months and the last one was conducted on 6/1/23. Facility Administrator is adhering to operational requirements.

Physical Plant & Environment Safety: The home is located in a residential area, the single-story facility consisting of: The facility consists of : 2 resident bedrooms, 2 bathrooms (1 staff bathroom), kitchen/ dining, living room and yard area. Physical plant inside and outside is in good repair. All resident rooms were checked. All resident beds have the required linens which were in good condition at the time of the visit. All bedrooms had sufficient closet/ storage space. Bathrooms are clean and operational and were observed to be within Title 22 regulations. Facility toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients. Bathrooms are clean, sanitary and operational with grab bars and non skid mats in place. Water temperature properly measured at 113.9F*. Facility temperature was comfortable throughout the facility. LPA observed the facility to be clean and in good repair. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher is fully charged. Exit, walkways and/or passageways, front yard is free of debris and/or hazards. A shaded area with chairs is provided for residents in the front porch of the facility

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator certificates expired 3/27/2023. Administrator stated the renewal documents were submitted to the recertification unit but an Administrator Certificate has not been received yet. Proof of document submittal was provided.

Refer to LIC 809C for continuation of report

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FOREVER YOUNG AGAIN	FACILITY NUMBER: 198603120
	VISIT DATE: 08/28/2023

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

Resident Records-Incident Reports: LPA reviewed Client files for R1 through R4. Resident files are maintained at the facility and have the following documents in their files : Admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment/Appraisals, hospice care plans, and emergency information.

Resident Rights-Information: RCFE complaint poster and Personal rights were observed posted in the facility as well as LTCO poster. Per Facility Administrator, facility provides wi-fi services for facility residents.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician order for modified diet is on file. Sanitation practices and kitchen cleanliness was observed.

Incidental Medical Services: Four (4) centrally stored 30-day supply of medications were reviewed. Medical and dental transportation is provided by facility, and family members. Access is also used.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. The last quarterly fire/emergency drill was completed on 6/1/2023.

Residents with SHN : Two (2) residents receive hospice care. Postural support physician orders are on file. Appraisals were observed in resident files. No residents have prohibited health conditions.

No deficiencies noted. Exit interview and a copy of this report was provided to Administrator Martiniana Laureta.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3