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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801028
Report Date: 07/21/2022
Date Signed: 07/21/2022 03:12:06 PM


Document Has Been Signed on 07/21/2022 03:12 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:GOLDEN APRICOT MANORFACILITY NUMBER:
197801028
ADMINISTRATOR:SERBAN, NICULINAFACILITY TYPE:
740
ADDRESS:16875 SAUSALITO DR.TELEPHONE:
(562) 694-5282
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:10CENSUS: 9DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator Niculina Serban and Assistant Administrator Felipe De CastroTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Jose Villalobos made and unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Administrator Niculina Serban and Assistant Administrator Felipe De Castro. The purpose of the visit was discussed.

As a part of the inspection, LPA used the inspection tool, reviewed (4) resident records, (2) staff files, and (4) resident medications. Currently the facility has (9) residents of which (9) are non-ambulatory. Facility is a one story family home with ten (10) resident bedrooms, two (2) bedrooms for live in staff, 10 (10) bathrooms, living room, kitchen, central air and heating, dining area, laundry room, a shaded area located in the backyard. an attached garage inaccessible to residents. Front and back yard is in good condition at time of visit. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to residents. Bedrooms #1-#10 have required furnishing. Bathrooms have a working toilet, wash basin, and shower. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies were observed. Fire alarms are interconnected and operational. Required postings observed. Water temperature within required tittle 22 regulations. Last Fire Drill on 7/10/22.

Infection control domain completed and there were no deficiencies. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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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