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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607201
Report Date: 08/21/2022
Date Signed: 08/21/2022 08:27:29 PM


Document Has Been Signed on 08/21/2022 08:27 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:GOLDEN CITY HOME CAREFACILITY NUMBER:
197607201
ADMINISTRATOR:ANTONIA DIONISIOFACILITY TYPE:
740
ADDRESS:2451 W. 230TH STREETTELEPHONE:
(310) 325-1995
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 6DATE:
08/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Antonia DionisioTIME COMPLETED:
05:00 PM
NARRATIVE
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On 08/21/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Antonia Dionisio and explained the purpose of today’s visit. The facility is licensed to operate for (6) residents of which (5) non-ambulatory and may be (1) bedridden elderly residents ages 60 and above. The facility is approved for (1) hospice resident.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) residents' rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, and an outside patio area.

LPA toured the physical plant. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be operational. The water temperature measured 110.6 F. A comfortable temperature of 75 degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharp objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has (1) fire extinguisher that is charged, and smoke detectors operable. A working landline telephone remains available.

Evaluation Report continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2022
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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Document Has Been Signed on 08/21/2022 08:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: GOLDEN CITY HOME CARE
FACILITY NUMBER: 197607201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation), the licensee did not comply with the section cited above. LPA identified a twin size mattress obstructing exit passage way inside room #4. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2022
Plan of Correction
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The licensee will adhere to Title 22 Section 87307. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations and remove any object obstructing emergency passage exits. Plan of correction will be submitted by POC due date: 08/22/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/21/2022 08:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: GOLDEN CITY HOME CARE
FACILITY NUMBER: 197607201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(4)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation), the licensee did not comply with the section cited above. LPA observed the garage cluttered with furnishings with evidence of rodent droppings and ants. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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The licensee will adhere to HSC 1569.18. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. The licensee will hire a pest control company to spray the inside of the garage and the perimter of the external home. The licensee will organize the garage and dispose any furnishings no longer needed. Plan of correction will be submitted by POC due date: 09/21/22. A receipt from Pest Control Company is required.
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) , the licensee did not comply with the section cited above. LPA identified the kitchen stove and overhead microwave oven fille with build up grease and food particles. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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The licensee will adhere to Title 22 Section 87555. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. Plan of correction to do a deep cleaning of the kitchen and appliances. Correction will be submitted by POC due date: 09/06/22.

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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN CITY HOME CARE
FACILITY NUMBER: 197607201
VISIT DATE: 08/21/2022
NARRATIVE
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INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff tests and residents' vaccination along with daily temperature checks were conducted. The facility has an approved Mitigation Plan Report on file with CCLD.

DEFICIENCIES:
LPA identified the kitchen stove and overhead microwave filled with build up grease and food particles. LPA observed a twin size mattress obstructing the emergency exit passage in room #4.. LPA observed the garage cluttered with unused mattresses other furnishings with rodent droppings and ants. LPA identified staff #2 with an expired 02/13/22 CPR/First Aid. The facility does not have a current liability insurance on file.

Deficiencies are issued and an exit interview is conducted with Antonia Dionisio. A copy of this report is provided along with the appeal rights.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/21/2022 08:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: GOLDEN CITY HOME CARE
FACILITY NUMBER: 197607201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General -Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above. LPA identified staff #2 had an expired CPR/First Aid dated 02/13/22. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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Licensee will ensure that staff complete CPR training and submit copies of certificates to CCL by POC due date via fax 323-981-1781 attn: LPA Ernand Dabuet.
Type B
Section Cited
HSC
1569.605
Liability Insurance; coverage requirements- On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and hree million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. The requirement is not met as evidenced by: On 08/22/19 & 09/20/19 CCLD requested proof of Liability Insurance. As of today's visit, CCLD has not receive proof of Liability Insurance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (interview), the licensee did not comply with the section cited above. Licensee informed LPA no liability insurance on file. The coverage has expired and did not have a current insurance for coverage. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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The licensee will ensure all residential care facilities for the elderly shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars per occurrence and three million dollars in the total annual aggregate. The administrator will send the copy of the liability insurance to LPA Dabuet by 09/06/22

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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5