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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609611
Report Date: 10/06/2021
Date Signed: 10/06/2021 01:00:10 PM

Document Has Been Signed on 10/06/2021 01:00 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOODEN RESIDENTIAL WELLNESS CENTER #3, THEFACILITY NUMBER:
197609611
ADMINISTRATOR:BRANDON BREWERFACILITY TYPE:
772
ADDRESS:2520 CROSS STREETTELEPHONE:
(626) 356-0078
CITY:LA CRESCENTASTATE: CAZIP CODE:
91214
CAPACITY: 6CENSUS: 3DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Cory Michell, Compliance Officer TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required One (1) year Infection Control inspection to the facility. LPA met with Cory Mitchell, Compliance Officer and explained the reason for the visit.

A tour of the physical plant was conducted at 10:00 am and the following was noted:

There is only one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. LPA was screened upon entry.

The facility had submitted and approved Mitigation Plan.

BEDROOMS: Located on the second and third levels. There were three bedrooms designated for client use, all furnished for double occupancy. There were sufficient supplies of bedding and linens. There were no visible hazards.

BATHROOMS: Located on the second and third levels. There are three full bathrooms. Two designated for the use of clients only and one available for both clients and staff. All bathrooms had functional fixtures and appeared clean and sanitary with no visible hazards. The hot water in the second floor delivered at 117.2 F.

COMMON AREAS: Located on the second level. These included the dining room and living room. All common areas were adequately furnished to accommodate that maximum capacity of 6 clients. There were no visible hazards.

(Continue-809C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOODEN RESIDENTIAL WELLNESS CENTER #3, THE
FACILITY NUMBER: 197609611
VISIT DATE: 10/06/2021
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KITCHEN: Located on the second level. There were sufficient supplies of cook ware and dining ware. Appliances and fixtures appeared clean and in good repair. The hot water delivered at 118.2 F. Food is cooked at an off site location in one of the facilities main homes, It is delivered daily three times a day to the facility.

LAUNDRY ROOM: This was located on the ground level. There are adequate laundry appliances to accommodate the maximum capacity of 6 clients.

SURROUNDING GROUNDS: The grounds included garden and lawn areas. There were patios and covered areas that provide shade. Entrances to the garage and storage areas were secured and inaccessible to clients. There is no body of water.

The facility maintains a comfortable temperature at 73 degrees. The smoke detectors and carbon monoxide detectors are observed to be operational. Fire extinguishers were last serviced in November of 2020.

Medications-LPA observed medication and toxic chemicals in the downstairs closet to be locked and inaccessible to residents. There is one (03) complete first aid kits.

Exit interview conducted. A copy of this report was issued .
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC809 (FAS) - (06/04)
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