197606170-6-2-2021-11-AS-TAGD-C3LTP6-20210602145346

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606170
Report Date: 06/02/2021
Date Signed: 06/02/2021 02:54:51 PM

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	GOLDEN MANOR REST HOME		FACILITY NUMBER:	197606170
ADMINISTRATOR:	MARK INGBER		FACILITY TYPE:	740
ADDRESS:	3535 OVERLAND AVENUE		TELEPHONE:	(310) 836-0510
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY:	98	CENSUS: 56	DATE:	06/02/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:36 AM
MET WITH:	Judith Muro, Personal Assistant		TIME COMPLETED:	02:45 PM

NARRATIVE

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On 06/02/2021 at 11:36am, Licensing Program Analyst (LPA) Troy Agard conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Agard conducted a risk assessment at the front entrance. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility submitted a mitigation plan report.

The facility is licensed for (98) ambulatory residents, of which (42) may be non-ambulatory. There are currently no hospice waiver or bedridden residents at the facility.

LPA Agard met with the Assistant to Administrator, Judith Muro and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked. LPA was properly equipped with Fit tested N-95 and gloves.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid temperature log. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored onsite 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 staff, residents, and visitors maintain 6 feet physical distancing, and each person wears a face covering. LPA observed required postings throughout the facility.

LPA reviewed the facility’s surveillance testing records. All staff is tested every other week. Staff have not completed the N-95 fit testing. Covid-19 Infection Control and Prevention training records and in-service training was reviewed. LPA did not observe newly admitted residents or newly hired staff

The facility does not support residents with dementia and does not have a memory care unit. A vacant room was inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN MANOR REST HOME	FACILITY NUMBER: 197606170
	VISIT DATE: 06/02/2021

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resident personal belongings was observed. Furniture in common areas are clean, in good repair and also socially distanced.

There are no security bars or 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 118 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-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.

One Advisory note was issued for:

1) Fit testing

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

LIC809 (FAS) - (06/04)

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