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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607201
Report Date: 09/07/2023
Date Signed: 09/07/2023 04:12:39 PM


Document Has Been Signed on 09/07/2023 04:12 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 ASC, 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: 5DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Antonia DionisioTIME COMPLETED:
04:10 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
On 09/07/2023 at 2:00 PM, Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with Antonia Dionisio, Administrator. Five (5) residents and two (2) staff were present during this inspection.

Facility is licensed to serve five (5) non-ambulatory residents and one (1) bedridden resident. The facility also has an approved hospice waiver for one (1) resident. The facility currently has 4 non-ambulatory residents and 1 resident receiving hospice services.

The home consists of 1 floor level with: 4 resident rooms, 2 restrooms, kitchen, dining room, laundry room, garage, and outdoor area.

During today's visit, LPM and LPA conducted a tour of the physical plant, reviewed food supply, medication, emergency disaster plan (LIC610D) and infection control plan, and conducted interviews with two staff members and three residents.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding criminal record clearance warrants an immediate civil penalty of $100.00 and is hereby assessed, see LIC421IM

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left wit Administrator, Antonia Dionisio.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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 6


Document Has Been Signed on 09/07/2023 04:12 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: GOLDEN CITY HOME CARE
FACILITY NUMBER: 197607201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Physical Plant/Environmental Safety - Row46 Section 87307(d)(6) - Domain Focused
(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
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in room three (3). During today's, LPA observed bed B obstructing the doorway leading to the outdoors, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
1
2
3
4
Administrator agreed to make adjustments to ensure that bed B in room 3 will not obstruct the doorway. Proof of corrections will be emailed to regina.cloyd@dss.ca.gov
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: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 09/07/2023 04:12 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: GOLDEN CITY HOME CARE
FACILITY NUMBER: 197607201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above, LPA did not observe an infection control plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
1
2
3
4
The administrator agreed to submit an Infection Control Plan for approval. Proof of correction will be submitted to CCL via email to regina.cloyd@dss.ca.gov
Type B
Section Cited
CCR
87355(e)(4)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above. During today's visit, LPA observed staff Marisol Bade (S1) present at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2023
Plan of Correction
1
2
3
4
The administrator agreed to submit a criminal record transfer request to CCL. Proof of correction will be submitted to CCL via email to regina.cloyd@dss.ca.gov
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: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 09/07/2023 04:12 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: GOLDEN CITY HOME CARE
FACILITY NUMBER: 197607201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. During today's visit, LPA observed that the facility did not have an updated LIC 610E, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
1
2
3
4
The administrator agreed to submit an updated Emergency Disaster Plan (LIC 610E) for approval. Proof of correction will be submitted to CCL via email to regina.cloyd@dss.ca.gov
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: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6