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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801028
Report Date: 10/01/2021
Date Signed: 10/01/2021 04:45:43 PM

Document Has Been Signed on 10/01/2021 04:45 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 APRICOT MANORFACILITY NUMBER:
197801028
ADMINISTRATOR:SERBAN, NICULINAFACILITY TYPE:
740
ADDRESS:16875 SAUSALITO DR.TELEPHONE:
(562) 694-5282
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 10CENSUS: 7DATE:
10/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Niculina Serban, Administrator TIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Galarza and Baptiste conducted a visit in regards to complaint visit control #: 28-AS-20210928141407. During the complaint visit deficiencies were observed. The purpose of the visit was discussed Administrator Niculina Serban, Assistant Administrator Felipe DeCastro and Administrative Assistant Joanna Decastro.

Physical Plant Observations:
  • At 9:36 am 2 knives were observed on the dish rack, and the knives/sharps drawer was unlocked. Staff locked all the knives during the visit. Pictures were taken.
  • At 9:53 AM, LPAs observed one of the side gates had a lock that requires a key. LPA spoke to LA County Fire Department. It was explained to Assistant Administrator that locked perimeter gates are not allowed per fire safety code. Staff removed it during the visit. Pictures were taken.
  • During physical plant inspection LPAs observed that none of the resident beds had mattress pads. One (1) resident has a hospital bed that did not have a fitted sheet on the mattress.

Deficiencies are cited in LIC 809D.


Exit interview was conducted with Niculina Serban. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 10/01/2021 04:45 PM - It Cannot Be Edited


Created By: Noemi Galarza On 10/01/2021 at 03:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN APRICOT MANOR
FACILITY NUMBER: 197801028

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/01/2021
Section Cited
CCR
87705(I)(2)

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Care of Persons with Dementia. The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:
The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.
This requirement was not met by evidence of:
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Assistant Administrator removed the lock from the side gate.

***Cleared during the visit.
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Based on physical plant inspection at 9:53 AM LPA observed one of the side gates had a lock that requires a key. LPA spoke to LA County Fire Department; it was explained to Assistant Administrator that locked perimeter gates are not allowed per fire safety code. This poses an immediate healt and safety risk.
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Type A
10/01/2021
Section Cited
CCR87705(f)(1)

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Care of Persons with Dementia. 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 was not met by evidence of:
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Staff removed the unlocked knives observed in the dish rack and unlocked sharps drawer.

***Cleared during the visit.
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Based on observation at 9:36 am 2 knives were observed on the dish rack, and the knives/sharps drawer was unlocked. This poses an immediate healthy & safety risk to residents in care.
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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 Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/01/2021 04:45 PM - It Cannot Be Edited


Created By: Noemi Galarza On 10/01/2021 at 04:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN APRICOT MANOR
FACILITY NUMBER: 197801028

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2021
Section Cited
CCR
87307(a)(3)(C)

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Personal Accommodations and Services. Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths.....
This requirement was not met by evidence of:
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Administrator agreed to ensure that all resident beds have mattress pads, and sheets at all times.

Submit proof of correction by POC due date.
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Based on physical plant observations none of the residents in care (total of 7) had mattress pads on their beds. One (1) resident's hospital bed did not have sheets on the mattress. This poses a potential health and safety risk.
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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 Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2021


LIC809 (FAS) - (06/04)
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