198203004-10-12-2021-11-AS-MCAA-C8CVJM-20211101162854

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198203004
Report Date: 09/10/2021
Date Signed: 10/12/2021 02:31:44 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2021 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20210907092149

FACILITY NAME:	GOLDEN SEASONS		FACILITY NUMBER:	198203004
ADMINISTRATOR:	CESAR FELICIANO		FACILITY TYPE:	740
ADDRESS:	1116 CERISE AVENUE		TELEPHONE:	(310) 320-7178
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS:	DATE:	09/10/2021
		UNANNOUNCED	TIME BEGAN:	02:24 PM
MET WITH:	Bien Cadungog		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility has several wasp nests under the eaves of the home.
The eaves of the home are deteriorating.
Part of the brick wall outside the home is falling down.
There is garbage in the yard of the facility.

INVESTIGATION FINDINGS:

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On 09/10/21 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced visit regarding
The allegations above. LPA was met by Care giver Delia and the purpose of the visit was explained.

The investigation Consisted of Tour of Physical plant, Interviews with Residents, and staff.

Regarding Allegation: Facility has several Wasp Nest under the eaves of the home.
LPA Observed a total of 3 wasp nest, at 1:45pm. Two of which had wasps, and
wasp eggs present. One Large, and Medium size wasp nest were located in eaves of the back de-
attached Garage used for storage, on the Right hand side, and one small one in the front overhang of
the home. Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) us found to be SUBSTANTIATED. California Code Of Regulations, are being cited on the attached LIC 9099 D.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210907092149

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN SEASONS	FACILITY NUMBER: 198203004
	VISIT DATE: 09/10/2021

NARRATIVE

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Regarding Allegation: Facility Eaves of the home are deteriorating

LPA observed that the eaves around the perimeter of the entire home, including the back garage

Are cracked and deteriorating. LPA observed Dicoloration, surface cracks on the wood, and chipped paint on the outside, and underneath the eaves of the facility. Therefore; Based on LPAs observations the preponderance of evidence standard has been met, therefore the above allegation(s) us found to be SUBSTANTIATED. California Code Of Regulations, are being cited on the attached LIC 9099 D.

Regarding Allegation: Part of the brick wall outside the home is falling down.

Lpa Observed a Brick wall that divides the property to be incomplete and missing bricks. There has been another wall that was built to separate the neighbor and facility property line. Based on interviews, the neighbor offered to go 50/50 on the wall that divides the property, but the owner of the home did not

Comply, therefore the neighbor had their own contractor build a new wall on their property line. Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) us found to be SUBSTANTIATED. California Code Of Regulations, are being cited on the attached LIC 9099 D.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20210907092149

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN SEASONS	FACILITY NUMBER: 198203004
	VISIT DATE: 09/10/2021

NARRATIVE

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Regarding Allegation: There is garbage in the yard of the facility

LPA Observed an Old hospital Bedframe outside in the back yard. Facility staff stated that someone was coming to get the bed. Windows were also being replaced, and old shutters were observed outside towards the walls of the facility.

Based on LPA Observation the preponderance of evidence standard has been met, therefore the above allegation(s) us found to be SUBSTANTIATED. California Code Of Regulations, are being cited on the attached LIC 9099 D.

An exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210907092149

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN SEASONS	FACILITY NUMBER: 198203004
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/01/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and Visitors. This requirement was not met as evidenced by: Based on LPA observation there was a 3 wasp nest underneath the eaves of the home/garage, there was a broken/unfinished brickwall	1 2 3 4 5 6 7	Administrator will submit a photograph and pest control plan of wasp nest being disguarded. Will submit either contract plan for eaves, or photograph to show they have been fixed around the home, and will send picture of backyard free of debris. To LPA by POC due date 10/01/21.
	8 9 10 11 12 13 14	there cracked wood, chipped paint and discolorarion of eaves around perimeters of the home,a broken/unfinished brickwall, and trash in the form of unusued bed and shutter that had not been disguarded. This poses a potential health,safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

LIC9099 (FAS) - (06/04)

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