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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801028
Report Date: 06/12/2023
Date Signed: 06/12/2023 03:09:16 PM


Document Has Been Signed on 06/12/2023 03:09 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: 6DATE:
06/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Administrator Joanna De Castro TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos made and unannounced Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. On today’s visit LPA met with Administrator Joanna De Castro. The purpose of the visit was discussed.

The following were observed/inspected:
Physical Plant: 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. Passageways are free of obstruction. Water temperature measured within compliance. Smoke/carbon monoxide detectors were tested and operational. Fire extinguishers observed. Required postings observed. Central Air and Heating with temperature comfortable. Emergency supplies observed. Appliances such as a microwaves, refrigerators, and stoves were observed to be clean and operating properly. Nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. Food utensils were clean and sufficient for the number of residents to be served. MEDICATION: Medications are stored, locked and inaccessible to residents. Six (6) Resident medications were observed. First Aid Kit Observed RECORD REVIEW: Five (5) Staff Files reviewed. Six (6) Resident files reviewed. ACTIVITIES: LPA observed activities for resident use as well as sufficient space and accommodations for residents to do activities. POSTINGS: All necessary postings were observed to be posted in appropriate places. A current Plan of Operations and Disaster plan is maintained at the facility. Operating telephone was observed and available for resident use.

Care Tool was completed and based on Title 22 Regulations, no Deficiencies will be documented.

An exit interview was conducted and a copy of today's report was provided and discussed.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023
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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