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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203004
Report Date: 12/21/2023
Date Signed: 12/21/2023 11:43:34 AM


Document Has Been Signed on 12/21/2023 11:43 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
EL SEGUNDO, 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:
12/21/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Bien Cadungog-LicenseeTIME COMPLETED:
11:43 AM
NARRATIVE
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On 12/21/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Bien Cadungog/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above. All bedrooms are cleared for bedridden residents. Hospice waiver approved for (1) 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 Iniguez toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (2) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #1, #2, and #3 and smoke and carbon monoxide combo are all operable conditions. The water temperature properly measured between 105°-120°F: Kitchen 107.5°F, Bathroom #1:106.7°F, Bathroom #2:108.1°F.

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN SEASONS
FACILITY NUMBER: 198203004
VISIT DATE: 12/21/2023
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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene observed, 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. All fire extinguishers were charged and were operable. A review of (2) residents' service files, (2) staff personnel files and (2) Medication Administration Records (MAR) were maintained in order. First AID kit was checked. Last fire disaster drill was on: 3/1/2023.

LPA observed the facility's infection control practices. A copy of the liability insurance will be email to LPA.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. (See D page for details)



An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Bien Cadungog /Administrator.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/21/2023 11:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: GOLDEN SEASONS
FACILITY NUMBER: 198203004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in keeping cleanning supplies unlocked at the facility(bathroom and patio area) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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Lincensee removed cleanning products while LPA was at the facility. In addition, Licensee will ensure all cleaning supplies are locked at all times. As part of POC, licensee will conduct an all staff training regarding keeping cleaning supplies locked at all time. Licensee will email copy of training to LPA via email before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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