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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606170
Report Date: 05/18/2024
Date Signed: 05/18/2024 01:48:11 PM


Document Has Been Signed on 05/18/2024 01:48 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:GOLDEN MANOR REST HOMEFACILITY NUMBER:
197606170
ADMINISTRATOR:MARK INGBERFACILITY TYPE:
740
ADDRESS:3535 OVERLAND AVENUETELEPHONE:
(310) 836-0510
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY:98CENSUS: 64DATE:
05/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:56 AM
MET WITH:MAGDALENA ROMEROTIME COMPLETED:
02:00 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
On 05/18/24, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Required- 1 Year visit to Golden Manor Rest Home. Upon arrival at the facility, Licensing Program Analyst (LPA) verified that the facility submitted a mitigation plan report.

The facility is licensed to serve 98 residents of which (42) may be non-ambulatory. There are currently no hospice waiver or bedridden residents at the facility. LPA met with Magdalena Romero and we both toured the inside and outside grounds of the facility.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored on site in a locked cabinet. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the front patio, courtyard or in the front living room, in addition to the resident’s bedroom. LPA observed required postings throughout the facility. The facility does not support residents with dementia and does not have a memory care unit. A room was inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Furniture in common areas is clean.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GOLDEN MANOR REST HOME
FACILITY NUMBER: 197606170
VISIT DATE: 05/18/2024
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
There are no weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. The water temperature measured at 108.3f degrees Fahrenheit in residents’ room and within regulation in the common area. A comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed a two day supply of perishable and a seven (7)-day supply of non-perishable food. Knives and toxins were kept locked and separate. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to resident in care. The First Aid kit was available and inaccessible to residents. Several fire extinguishers were observed throughout the facility.

Outside grounds were toured, and no bodies of water were observed. Walkways around the facility were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report was provided to staff Magdalena Romero.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2