197607756-7-24-2023-28-AS-NGAA-CU2RTA-20230724131801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607756
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:18:10 PM

Document Has Been Signed on 07/24/2023 01:18 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 LIVING		FACILITY NUMBER:	197607756
ADMINISTRATOR:	ANA SANTOS		FACILITY TYPE:	740
ADDRESS:	438 N. CALIFORNIA STREET		TELEPHONE:	(626) 287-6792
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	6	CENSUS: 3	DATE:	07/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:19 AM
MET WITH:	Ana Santos, Administrator		TIME COMPLETED:	12:50 PM

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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Ana Santo and Assistant Administrator Mauricio Santos. There are currently 3 elderly residents 60 years and older residing in the facility. One (1) resident is receiving hospice care, and two (2) residents have Dementia.

The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility submitted a COVID-19 Mitigation Plan, but an Infection Control Plan has not been submitted.

Operational Requirements:

A current Plan of Operation was reviewed.
The facility has a Dementia Waiver in place. A Hospice Waiver for 2 is approved.
A fire clearance for 6 non-ambulatory adults 60 and over; of which three (3) may be bedridden in rooms 2, 3, and 4 only.
Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 10/6/2023.
A surety bond is not applicable. Facility does not handle resident's money.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

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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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
	VISIT DATE: 07/24/2023

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Physical Plant/Environment Safety:

The facility is a single story home located in a residential neighborhood that is licensed for six (6) non- ambulatory residents, of which 3 may be bedridden. The facility is owner operated and consists of 5 bedrooms; 4 for residents [3 private & 1 shared) and 1 staff bedroom for licensee, 3 bathrooms, 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 interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Kitchen drawers containing knives/sharp objects were unlocked. Citation was issued.
An updated fire clearance was granted on 6/17/2023 for a capacity increase of 4 to 6 residents. The clearance was approved for 6 non-ambulatory; of which of which three (3) may be bedridden in rooms 2, 3, and 4 only.
The facility has one (1) fully charged fire extinguisher and fire sprinklers.
Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Water temperature ranged between 101.6 - 109.9 degrees Fahrenheit.

Staffing:

A total of 4 caregiver staff provide care and supervision to the clients.

Personnel Records/Staff Training:

Administrator certificates expires 3/26/2024.
Personnel files/training were reviewed. Proof of staff training, health clearance, criminal background clearance and 1st Aid/CPR training were verified.
Staff (S3) has criminal background clearance but is not associated to the facility. Citation was issued.

***narrative continues next page***

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 07/24/2023

NARRATIVE

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Resident Records/Incident Reports:

A total of three (3) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information.
RCFE complaint poster and Personal rights were observed posted in the facility entrance area.

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.
Indoor and outdoor activities are performed daily.
The facility does not have a Resident Council.

Food Service:

Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
No Physician orders for modified diets are in place.
Sanitation practices and kitchen cleanliness was observed.

Incident Medical and Dental:

Three (3) centrally stored resident medications were observed to have a 30-day supply of medications.
Medical and dental transportation is provided by family members.

Disaster Preparedness:

Emergency and Disaster Plan LIC 610E is in place.
The last emergency disaster drill was conducted on 3/24/2023.

See next page

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 07/24/2023

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Residents with Special Health Needs:

No residents are receiving home health services. One (1) resident is enrolled in hospice care.
Postural support physician orders are on file.
Half bed rails for mobility assistance were observed in resident beds.
Individual Service Plans and Appraisals were observed in resident files.
No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Administrator Ana Santos. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 07/24/2023 01:18 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: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 in that knives and sharps were unlocked in the kitchen drawers; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/24/2023
	Plan of Correction
1 2 3 4	Administrator immediately placed the knives/sharps in a locked drawer. CLEARED.

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance 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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 in that staff (S3) began working at the facility on 4/11/2023, and has not been associated to the facility; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2023
	Plan of Correction
1 2 3 4	Administrator agreed to associate S3 to the facility via Guardian and/or submit in-person to CCL by tomorrow. Submit proof of correction.

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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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