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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320024
Report Date: 09/01/2023
Date Signed: 09/01/2023 03:53:18 PM


Document Has Been Signed on 09/01/2023 03:53 PM - 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 CARE LIVING IIIFACILITY NUMBER:
198320024
ADMINISTRATOR:GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:1308 HICKORY AVETELEPHONE:
(310) 787-8369
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 5DATE:
09/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Catherine EspinoTIME COMPLETED:
04:00 PM
NARRATIVE
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On 09/01/2023, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced annual required visit using the new CARE Inspection. LPA spoke with Administrator Catherine Espino over the phone explained the purpose of today’s visit. The facility is licensed to operate for six (6) nonambulatory of which two (2) may be bedridden in any room. The facilities annual fees are current.

LPA and Caregivers (S2 and S3; reference LIC859) toured the physical plant. This facility consists of five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, kitchen, living room, dining area, office area, shaded patios (located in the front yard and backyard), and a two car garage. One fire extinguisher last serviced on 2/10/2023 is located near the kitchen.

There were no bodies of water on the premises. A comfortable temperature was maintained in the facility.

LPA conducted a records review of (5) client records and (5) staff records (LIC 500 Roster and two staff files were unavailable). LPA reviewed (5) Client Medication Administration Records and observed discrepancies at the time of visit.

Deficiencies were observed during today’s visit but due to time constraints an Annual Continuation visit will be conducted.

A copy of this report, review of staff/volunteer records (LIC 859), and resident’s records review (LIC 858) was provided to the facility.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
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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Document Has Been Signed on 10/02/2023 08:59 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/06/2023 11:32 AM

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 CARE LIVING III
FACILITY NUMBER: 198320024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personal Accommodations and Services
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
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Based on observation, the licensee did not comply with the section cited above during today's visit, LPA observed bleach in the backyard, knives in the kitchen drawer, and cleaning solution under the kitchen sink and in the garage accessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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The administrator agreed to store the above said items and ensure that they are inaccessible to residents in care. The administrator also agreed to create a plan to ensure the future compliance to Title 22 regulation 87309(a) Storage Space. Proof of correction will be submitted to regina.cloyd@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 CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2023 03:42 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/06/2023 02:50 PM

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 CARE LIVING III
FACILITY NUMBER: 198320024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of five staff records were unavailable on September 1, 2023 visit, which poses a potential safety risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Administrator will ensure that Personnel Records (listed on LIC 500 Personnel Report) are complete and on site. Administrator will email proof of Personnel Report and missing staff records to regina.cloyd@dss.ca.gov
Section Cited
Other Provisions
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: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document is an Amendment of Original Document on 09/06/2023 03:13 PM

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 CARE LIVING III
FACILITY NUMBER: 198320024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
Deficient Practice Statement
1
2
3
4
This page was intentionally left blank.
POC Due Date:
Plan of Correction
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2
3
4
Section Cited
Other Provisions
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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 CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 10/13/2023 09:07 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/06/2023 03:35 PM

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 CARE LIVING III
FACILITY NUMBER: 198320024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.319(a)
Regulations
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and interview of staff, the licensee did not comply with the section cited above, during today's visit staff stated that the facility does not provide common internet access device for residents' use, which poses a potential personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Administrator will ensure that residents will have access to at least one internet access device that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions. Proof of correction will be emailed to regina.cloyd@dss.ca.gov
Type B
Section Cited
CCR
87625(b)(8)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (8) Privacy shall be afforded when care is provided.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview of S3, the licensee did not comply with the section cited above in two out of five residents who shared room number three are not afforded privacy during routine hygiene care which poses a potential personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Administrator will create a plan to ensure that residents are afforded privacy during routined hygiene care. Proof of correction will be emailed to regina.cloyd@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 CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5