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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203004
Report Date: 08/04/2022
Date Signed: 09/09/2022 11:48:55 AM

Document Has Been Signed on 09/09/2022 11:48 AM - 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GOLDEN SEASONSFACILITY NUMBER:
198203004
ADMINISTRATOR:CESAR FELICIANOFACILITY TYPE:
740
ADDRESS:1116 CERISE AVENUETELEPHONE:
(310) 320-7178
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 2DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:VIENVENIDO CADUNGOGTIME COMPLETED:
03:00 PM
NARRATIVE
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On 8/4/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival at the facility, LPA Montoya called, spoke with Caregiver David Bandola and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection.

LPA met with Caregiver David Bandola and spoke with Staff Bienvenido Cadungog on the phone. LPA explained to Staff Cadungog the purpose of the visit. Shortly after, Staff Cadungog arrived and assisted LPA with the visit.

The facility is licensed to serve six (6) elderly residents ages 60 and older. All bedrooms are cleared for bedridden residents. Facility is approved for one (1) hospice resident.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, living area, dining area, kitchen, and outside covered patio area.

LPA Montoya toured and inside and outside grounds of the facility with Staff Cadungog. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 149.4 degrees Fahrenheit. A comfortable temperature was maintained in the facility.

LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has one (1) fire extinguisher that was last serviced on 3/7/2022; smoke detectors, and carbon monoxide were operable. The facility conducted a Fire/Safety Drill on 4/20/2022. A working telephone number 310-320-7178 remains available.

Evaluation Report Continues on LIC 809-
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/04/2022
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD. LPA did not observe screening protocols for residents, staff, and visitors.

Advisory Note - Technical Assistance was issued, please see LIC9102-AN.

Deficiencies are being cited based on LPA's observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. Civil penalty assessed.

An exit interview was conducted, Plans of Corrections were reviewed and developed with Staff Cadungog. A copy of this report and appeal rights were discussed and emailed to Staff Bienvenido Cadungog due to a technical difficulty.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/09/2022 11:48 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 09/08/2022 at 01:25 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN SEASONS
FACILITY NUMBER: 198203004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2022
Section Cited

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(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
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Based on observation and interview, the licensee did not comply with the section cited above. LPA Montoya observed the water temperature in a residents' common bathroom between resident bedrooms #2 and #3 measured at 149.4 degree Fahrenheit. This poses an immediate health, safety or personal rights risk to persons in care.
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Type A
08/05/2022
Section Cited

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA observed Caregiver (Staff #1) providing care and supervision to two residents during the visit. Based on interview with Staff #2, Staff #1 does not have criminal record clearance and not associated to the facility. Staff #2 stated Staff #1 does not have personnel records. Staff #1 admitted he commenced working for the facility on June 4 as a caregiver reliever. Staff #1 admitted he is working by himself supervising and providing care for two residents during LPA's visit. Staff #2 stated Staff #1 worked on 6/4/22, 6/25/22, 7/9/22 and 8/4/22. This poses an immediate health, safety or personal rights risk to persons 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2022 11:48 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 09/08/2022 at 01:30 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN SEASONS
FACILITY NUMBER: 198203004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2022
Section Cited

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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 is not met as evidenced by:
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Based on observation and interview, the licensee did not comply with the section cited above. LPA Montoya observed the kitchen cabinets, bathroom cabinets, garage, and underneath the outdoor patio have plenty of clutters. This poses a potential health, safety or personal rights risk to persons 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022


LIC809 (FAS) - (06/04)
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