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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606171
Report Date: 05/23/2025
Date Signed: 05/23/2025 12:18:53 PM

Document Has Been Signed on 05/23/2025 12:18 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:GOLDEN MANOR RETIREMENT CENTERFACILITY NUMBER:
197606171
ADMINISTRATOR/
DIRECTOR:		MARIA JACOBOFACILITY TYPE:
740
ADDRESS:1109 WEST BEVERLY BLVD.TELEPHONE:
(323) 724-3870
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY: 160TOTAL ENROLLED CHILDREN: 0CENSUS: 79DATE:
05/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Maria JacoboTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Carmen Virrueta and explained the reason for the visit.
The purpose of the visit is to complete the required inspection. Shortly thereafter Administrator Maria Jacobo arrived.
LPA Trueman toured the facility along with Staff Robert Blanco today 05/23/2025 at 9:00AM and the following was observed:
Facility contains 80 Bedrooms and 80 Bathrooms for residents, dining room, 2 TV rooms , and outdoor patio area..
LPA inspected 11 Rooms which included on the 1st Floor # 8, 16, 23, 32, and 70. On the 2nd Floor #35, 45, 46, 66, 72, and 77.
Hot water temperature measured between 105 F. and 120 F. meeting Title 22 Regulations.
Room 8 (107.9), Room 16 (112.4), Room 23 (113.5), Room 32 (114.2) and Room 70 (112.8).
Room 35 (106.2), 45 (109.2), Room 46 (110.4), Room 66 (107.2), Room 72 (112.2) and Room 77 (105.0)
Required Annual inspection included Infection Control Practices, Operational Requirements, Physical Plant/ Environmental Safety, 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.
LPA observed sufficient supply of 2 day perishables and 7 day non perishables.
All staff were cleared and associated.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Staff responsible for providing care and supervision received training in First Aid.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.

(cont. on 809 c )
Wei Siew HoTELEPHONE: (323) 981-3969
Glenn TruemanTELEPHONE: (323) 981-1652
DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2025
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN MANOR RETIREMENT CENTER
FACILITY NUMBER: 197606171
VISIT DATE: 05/23/2025
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Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
Medication was reviewed for 7 Resident's. 7 Resident Files and 5 Staff Files were reviewed.
Interviews were conducted with 5 Resident's and 3 Staff.

During tour of the facility it was observed in Resident Room 35 Screen in the sliding door and Room 45 that there is a tear in the window screen.
In Room 77 the Resident's mattress had a very large tear in the middle of the mattress.
Deficiencies to be cited on a new 809 Case Management - Deficiencies which contains the specific citations which are not located in the Care Tools.

Exit interview conducted.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC809 (FAS) - (06/04)
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