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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606171
Report Date: 06/29/2023
Date Signed: 06/29/2023 03:52:00 PM


Document Has Been Signed on 06/29/2023 03:52 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:MARIA JACOBOFACILITY TYPE:
740
ADDRESS:1109 WEST BEVERLY BLVD.TELEPHONE:
(323) 724-3870
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY:160CENSUS: 73DATE:
06/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria JacoboTIME COMPLETED:
04:00 PM
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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 Carmen Virrueta today 06/29/2023 at 11:15 AM 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 10 Rooms which included on the 1st Floor # 3, 20, 25, 26 and 31 and on the 2nd Floor # 36, 55, 61, 73 and 78.
Hot water temperature measured between 105 F. and 120 F. meeting Title 22 Regulations.
Room 3 (108.1), Room 20 (111.7), Room 25 (113.5), Room 26 (114.6) and Room 31 (115.5).
Room 36 (116.2), Room 55 (114.4), Room 61 (114.4), Room 73 (116) and Room 78 (117.1).
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.
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 7 Staff Files were reviewed.
Interviews were conducted with 5 Resident's and 3 Staff.
No deficiencies. Exit interview conducted.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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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