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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606171
Report Date: 05/19/2021
Date Signed: 05/20/2021 07:55:53 AM

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: 80DATE:
05/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Maria JacoboTIME COMPLETED:
03:00 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
Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Administrator Maria Jacobo and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.
LPA Trueman toured the facility along with Administrator Maria Jacobo today 5/19/2020 at 11:30 AM and the following was observed:
Facility contains 80 Bedrooms and 80 Bathrooms for residents, dining room, 2 TV rooms , and activity room.
Required Annual inspection included Infection Control Domain and check of the food supply, medications and criminal clearance check.
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.
Temperature checks are conducted 2x a day and logged.
Staff have been trained in hand washing. Staff are sufficient with no shortages and there is a plan to replace workers if ill. There are rooms available if isolation is needed. Staff wear masks, gloves and face shields.
Bathrooms have proper signage for hand washing. There are multiple stations for hand sanitizing.
Social distancing is implemented. Meal times are sanitized after each meal.
Facility has sufficient supply of PPE. Facility has a specific plan to ensure proper cleaning and disinfection of environmental surfaces and laundry; commonly touched surfaces are cleaned and disinfected at least once every shift . Plan when to notify medical provider if symptoms develop or COVID-19 exposure or when to call 911 for severe respiratory distress. Advisory notices issued (LIC 9102.)
Deficiency cited on 809 D for medication Banophen 25 mg, Benztropine 0.5 mg, and Risperidone 2 mg. moved from original bubble pack and placed in cups for future days of 5/20-22.
Exit interview conducted with Administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN MANOR RETIREMENT CENTER
FACILITY NUMBER: 197606171
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)5


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) the licensee did not comply with the section cited above by having residents medication Banophen 25 mg, Benztropine 0.5 mg, and Risperidone 2 mg. moved from original bubble pack and placed in cups for future days of 5/20-5/22 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2021
Plan of Correction
1
2
3
4
Administrator to schedule training with pharmacy to conduct medication training for all staff and submit signed log of those who attended by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2