197607201-6-4-2024-11-AS-UCOL-D6DSWP-20240619141438

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607201
Report Date: 06/04/2024
Date Signed: 06/04/2024 03:34:17 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/30/2024 and conducted by Evaluator Regina Cloyd

COMPLAINT CONTROL NUMBER: 11-AS-20240530152309

FACILITY NAME:	GOLDEN CITY HOME CARE		FACILITY NUMBER:	197607201
ADMINISTRATOR:	ANTONIA DIONISIO		FACILITY TYPE:	740
ADDRESS:	2451 W. 230TH STREET		TELEPHONE:	(310) 325-1995
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 5	DATE:	06/04/2024
		UNANNOUNCED	TIME BEGAN:	01:38 PM
MET WITH:	ANTONIA DIONISIO		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Staff did not ensure facility was free from pests.
Facility phone is in disrepair.

INVESTIGATION FINDINGS:

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On 06/04/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA was greeted by staff and explained the purpose of the visit. The Administrator joined us shortly afterwards. The investigation consisted of the following: During today’s investigation, LPA toured the facility.

Continue to LIC9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240530152309

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 06/04/2024

NARRATIVE

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Allegation(s):
Staff did not ensure facility was free from pests.

The investigation revealed the following: Regarding the allegation "Staff did not ensure facility was free from pests,” it is being alleged that the facility has vermin in the kitchen area. LPA observed vermin at the entryway, on the kitchen counters with staff present, and on the kitchen floor. The Administrator indicated that pest control was initiated on 05/30/24 and that service would not resolve the entire pest issue right away. Record review reveals that the payment for pest control was processed on 05/30/24. Regarding the allegation “Staff did not ensure facility was free from pests,” based on interview and observation the preponderance of evidence has been met therefore the allegation is Substantiated.

Deficiencies were issued.

An exit interview was conducted and plans of correction developed. A copy of this report and appeals rights was reviewed and left with the Administrator Antonia Dionisio.

Allegation(s):
Facility phone is in disrepair.

The investigation revealed the following: Regarding the allegation " Facility phone is in disrepair,” it is being alleged that the facility telephone is working but staff is unable to make or answer phone calls." LPA called the facility line and heard a call announcement through the television, but staff was unable to answer the call from the phones. LPA observed two facility phones with a “no power at base” notice and was unable to dial out. The Administrator indicated that her son plans to resolve the issue on 06/04/24 or on 06/05/24. Regarding the allegation “Facility phone is in disrepair,” based on interview and observation the preponderance of evidence has been met therefore the allegation is Substantiated.

Deficiencies were issued.

An exit interview was conducted and plans of correction developed. A copy of this report and appeals rights was reviewed and left with the Administrator Antonia Dionisio.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240530152309

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/04/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/11/2024 Section Cited CCR 87555(b)(27)	1 2 3 4 5 6 7	(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Administrator immediately emailed the bi-monthly pest control service agreement processed on 05/30/24 to LPA Cloyd. The Administrator will provide evidence of service rendered between 06/04/24 and 06/11/24 to regina.cloyd@dss.ca.gov
	8 9 10 11 12 13 14	Based on observation and interview, the licensee did not comply with the section cited above which poses a potential health and safety risk to residents in care. LPA observed vermin on the kitchen counters and on the kitchen floor.	8 9 10 11 12 13 14
Type B 06/13/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee will install new batteries/telephones inside of the facility and ensure that staff can receive incoming and make outgoing calls. The Administrator will provide evidence of correction to regina.cloyd@dss.ca.gov by the POC due date.
	8 9 10 11 12 13 14	Based on observation and interview, the licensee did not comply with the section cited above which poses a potential safety risk to residents in care. LPA observed that staff could not receive incoming calls nor make outgoing calls due to powerless phone bases.	8 9 10 11 12 13 14

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 Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

LIC9099 (FAS) - (06/04)

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