198203004-11-21-2024-11-AS-SLEO-DB8RBH-20241121115245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198203004
Report Date: 11/21/2024
Date Signed: 11/21/2024 11:52:57 AM

Document Has Been Signed on 11/21/2024 11:52 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	GOLDEN SEASONS		FACILITY NUMBER:	198203004
ADMINISTRATOR/ DIRECTOR:	CESAR FELICIANO		FACILITY TYPE:	740
ADDRESS:	1116 CERISE AVENUE		TELEPHONE:	(310) 320-7178
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY: 6		CENSUS: 3	DATE:	11/21/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Administrator - Bien Cadungog		TIME VISIT/ INSPECTION COMPLETED:	12:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/21/2024, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced continuation Required – 1 Year Inspection to the above-named facility and met with Administrator, Bien Cadungog. CCLD staff explained the purpose of the visit. On 11/20/2024, CCLD staff observed the following: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Earthquake and Disaster drill was conducted on 09/08/2024. There is a fire extinguisher in the kitchen area. There are landline telephones on the premises. There is a videoconferencing device dedicated for client use.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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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Document Has Been Signed on 11/21/2024 11:52 AM - It Cannot Be Edited

Created By: Socorro Leandro On 11/21/2024 at 10:24 AM

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: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff not having their negative Tuberculosis Test and 1 out 5 staff not having their Health Screening Report which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	The Administrator has agreed to email Staff 1's Tuberculosis Test Results and Staff 2's Health Screening Report along with their Tuberculosis Test Results to Socorro.Leandro@dss.ca.gov.

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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Socorro Leandro

LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/18/2025 11:00 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/04/2025 02:12 PM

Created By: Socorro Leandro On 11/21/2024 at 10:24 AM

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN SEASONS	FACILITY NUMBER: 198203004
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

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:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having bathroom 2's cabinet in disrepair, which poses a potential safety risk to persons in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	The Administrator has agreed to replace the bathroom cabinet sink with a cabinet in good repair. The Adminsitrator will email proof of correction to Socorro.Leandro@dss.ca.gov.

Type B

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having cleaning solutions accessible to residents in care(there were several cleaning solutions in the residents shower in bathroom 1), which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	The Administrator moved cleaning solutions to garage. The Admistrator agreed to create a plan where staff can have easy access to cleaning solutions while keeping cleaning products inaccessible to clients. The Administrator has agreed to re-train staff on how to properly store cleaning solutions. Administrator will email proof of correction to Socorro.Leandro@dss.ca.gov.

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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Socorro Leandro

LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/23/2024 04:32 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/20/2024 11:06 AM

Created By: Socorro Leandro On 11/21/2024 at 10:24 AM

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN SEASONS	FACILITY NUMBER: 198203004
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having evidence of vermen in the kitchen area, which poses a potential health risk to persons in care.
	POC Due Date: 12/31/2024
	Plan of Correction
1 2 3 4	The Administrator has agreed to create a plan for Facility Pest Control. The Administrator has agreed deep clean kitchen cabinets. The Administrator will email Facility Pest Control Plan and Steps they have taken to minimize vermin in facility and pictures of decluttered and organized kitchen cabinets to Socorro.Leandro@dss.ca.gov.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Socorro Leandro

LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN SEASONS	FACILITY NUMBER: 198203004
	VISIT DATE: 11/21/2024

NARRATIVE

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5 out of 5 bedrooms were checked. There is adequate lighting, plenty of dresser and closet space observed. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb. Evidence of vermin were observed in the facility and kitchen area. Bathroom 2’s cabinet was observed in disrepair. Cleaning solutions were observed accessible to clients in care.

3 out of 3 resident records were reviewed. 5 out of 5 staff records were reviewed.

CCLD staff had a case management conversation with Administrator regarding records, keeping facility in good repair, vermin, keeping cleaning solution out of reach of residents in care, etc.

A technical violation is being provided regarding keeping resident and staff records complete, current, and up to date.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN SEASONS	FACILITY NUMBER: 198203004
	VISIT DATE: 11/21/2024

NARRATIVE

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Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations (CCR), Title 22, see LIC809Ds. Violations regarding vermin, staff records regarding Tuberculosis Test Results & Health Screening Report, facility in good repair, and cleaning solutions accessible to residents in care. A violation regarding CCR 87309(a) cleaning solutions accessible to residents in care warrants an immediate civil penalty of $1000 and is hereby assessed, see LIC421M.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC809 (FAS) - (06/04)

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