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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607756
Report Date: 07/12/2022
Date Signed: 07/12/2022 01:45:08 PM


Document Has Been Signed on 07/12/2022 01:45 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 ROAD ASSISTED LIVINGFACILITY NUMBER:
197607756
ADMINISTRATOR:ANA SANTOSFACILITY TYPE:
740
ADDRESS:438 N. CALIFORNIA STREETTELEPHONE:
(626) 287-6792
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:4CENSUS: 3DATE:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Ana Santos, AdministratorTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Ana Santos and explained the purpose of the visit. There are 3 residents ages 60 and above. The facility has a Dementia waiver and a hospice waiver for 2 residents. The facility has one (1) hospice resident in place. It is a owner operated single story home located in a residential neighborhood that is licensed for 2 non- ambulatory and 2 bedridden residents.

LPA conducted an exterior and interior physical plant tour. The home consists of 5 bedrooms; 3 for residents [2 private & 1 shared) and 2 staff bedrooms for live-in staff, living room, dining room, kitchen, outdoor covered patio area, laundry room, and a 3 car detached garage in the rear of the property presently being used as storage area. The last emergency disaster drill was conducted on 3.22.2023. Administrator certificate expires 3/26/2024.

The following was inspected and observed during the inspection:
  • COVID-19 infection control signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Facility has an approved COVID-19 mitigation plan. LPA was screened upon entry by staff.
  • Each resident room is designated as the COVID-19 isolation room if needed.
  • Due to cognitive impairment residents in care do not wear masks.
  • Three (3) centrally stored resident medication records were reviewed. Facility maintains a 30-day supply of medications. Centrally stored medications are kept in a locked closet.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed.
  • Resident (R1's) file was reviewed. No physician order was on file for bed half rails.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
Deficiencies were cited. See LIC 809D.

Exit interview was conducted with Ana Santos . A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
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 07/12/2022 01:45 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: GOLDEN ROAD ASSISTED LIVING
FACILITY NUMBER: 197607756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

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 in that resident (R1's) bed had a half rail, but no physician order in file; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2022
Plan of Correction
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Administrator shall obtain a physician order for the bed half rail for resident (R1). Submit a copy of the physician order by tomorrow.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
LIC809 (FAS) - (06/04)
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