198320024-8-5-2021-11-AS-LMOA-C5KTAD-20210804143323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320024
Report Date: 08/04/2021
Date Signed: 08/05/2021 08:48:17 AM

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
MONTERY PARK, CA 91754

FACILITY NAME:	GOLDEN CARE LIVING III		FACILITY NUMBER:	198320024
ADMINISTRATOR:	GRADNEY, ANGELIQUE		FACILITY TYPE:	740
ADDRESS:	1308 HICKORY AVE		TELEPHONE:	(310) 787-8369
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 4	DATE:	08/04/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	ANGELIQUE GRADNEY		TIME COMPLETED:	01:00 PM

NARRATIVE

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On 8/4/2021 at 9:35 am, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Montoya called and, spoke with Administrator Angelique Gradney and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. The facility is licensed for six (6) non-ambulatory residents.

At around 9:50 am, LPA met with Caregiver Marian Manalang and they both toured the inside and outside grounds of the facility. At around 10:53 am, Administrator Angelique Gradney joined and assisted with the visit. LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance and visitors log. PPE supplies are readily available to staff, and an additional 30-day supply of PPE; sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the front patio, back patio and the living room. LPA observed staff and residents maintain 6 feet physical distancing, and each staff wears a face covering.

Based on LPA’s record review and interview with the Administrator, all four residents and four out of five staff have been vaccinated; N95 Fit testing has been completed and facility staff have been given training on Covid-19 Infection Control and Prevention training.

All rooms were inspected. Beds in shared bedrooms are 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly and the shower was free of

Report continued in LIC 809C

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

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
MONTERY PARK, CA 91754

FACILITY NAME: GOLDEN CARE LIVING III	FACILITY NUMBER: 198320024
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(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:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the hot water temperature used by residents was measured more than 120 degrees F. The following hot water temperature in resident bathrooms were observed: common bathroom/ 122.3 degrees F; inside room #4 - 122.9 degrees F and between bedrooms #1 & #2, 122.1 degrees F. This poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 08/05/2021
	Plan of Correction
1 2 3 4	Licensee adjusted the hot water temperature and it was measured at 113.0 degrees F. This was corrected during the visit.

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: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

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
MONTERY PARK, CA 91754

FACILITY NAME: GOLDEN CARE LIVING III	FACILITY NUMBER: 198320024
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(4)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, there are no grab bars inside the shower in the common bathroom used by residents. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2021
	Plan of Correction
1 2 3 4	Licensee shall install grab bars in the common bathrom used by residents. Licensee will send a photo of the installed grab bars by the POC due date.

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: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

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
MONTERY PARK, CA 91754

FACILITY NAME: GOLDEN CARE LIVING III	FACILITY NUMBER: 198320024
	VISIT DATE: 08/04/2021

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mold/mildew. The water temperature was measured at over 120 degrees F in all three bathroom used by residents. A comfortable temperature was maintained in the facility. All bedrooms and living room have smoke detectors and they are all interconnected and operational. Carbon monoxide detector located between the kitchen and the dining area was observed.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. The First Aid kit was available.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

Advisory Notes were issued, and Technical Assistance was provided.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Administrator Angelique Gradney.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

LIC809 (FAS) - (06/04)

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