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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603457
Report Date: 09/12/2024
Date Signed: 09/12/2024 09:37:08 AM

Document Has Been Signed on 09/12/2024 09:37 AM - 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:AYANNA HOME CAREFACILITY NUMBER:
198603457
ADMINISTRATOR/
DIRECTOR:		MATE, KELVINFACILITY TYPE:
740
ADDRESS:5602 WHITEWOOD AVETELEPHONE:
(909) 351-6012
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 6CENSUS: 4DATE:
09/12/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Elba Rodriguez - AdministratorTIME VISIT/
INSPECTION COMPLETED:
09:51 AM
NARRATIVE
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual continuation visit at the facility using the CARE Tool. LPA Mora met with the Administrator Elba Rodriguez and explained the reason for the visit.

During this visit, LPA Mora conducted another tour of the facility, interviewed 2 staff and 2 residents, reviewed the Emergency Disaster Plan, and delivered the findings for the annual visits conducted on 08/27/2024 and today.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was a deficiency observed during these annual visits (Refer to LIC 809-D). Exit interview held and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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Document Has Been Signed on 09/12/2024 09:37 AM - It Cannot Be Edited


Created By: Luis Mora On 09/12/2024 at 08:54 AM
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: AYANNA HOME CARE
FACILITY NUMBER: 198603457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

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 4 out of 4 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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Licensee is to comply with Title 22 Section 87412 at all times. Additionally, licensee will submit copies of Staff 1 - Staff 4 files to the Community Care Licensing Division (CCLD) by 09/19/2024.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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