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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320027
Report Date: 10/08/2024
Date Signed: 10/08/2024 09:33:02 PM


Document Has Been Signed on 10/08/2024 09:33 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:GOLDEN CARE LIVING IVFACILITY NUMBER:
198320027
ADMINISTRATOR:GRADNEY, STEPHENFACILITY TYPE:
740
ADDRESS:27711 HAWTHORNE BLVDTELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 6DATE:
10/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Charesa Reyes TIME COMPLETED:
02:39 PM
NARRATIVE
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On 10/08/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Cheresa Reyes. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory of which (1) maybe bedridden elderly adults ages 60 and above. Currently, the facility has (2) hospice resident in care. The facility is approved for (6) hospice residents.

The facility consists of one-story level: (4) resident bedrooms, (2) staff bedrooms, (1) bathroom, kitchen, dining room, living room/activity room and an outside patio.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 114.8 degrees F. A comfortable temperature of 77 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguisher were charged. The facility has conducted emergency fire drills on 10/01/24. A review of the Medication Administration Record (MAR) was observed to be maintained in order.

(Evaluation Report continues LIC 809-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 10/08/2024 09:33 PM - 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: GOLDEN CARE LIVING IV
FACILITY NUMBER: 198320027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section. LPA identified resident #6 not in hospice care with full bed rails. R6 had no prescription from PCP stating R6 requires full bed rails. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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LIcensee will adhere to Title 22 Reg 87608 and either remove the full bed rails or request a written prescription from PCP for approval. Proof of correction must be sent to LPA Dabuet by POC date at ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
87303(c)
(c) All window screens shall be clean and maintained in good repair.

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. LPA identified resident activity room sliding door and room #2 with no screens did not have a window screen. Hallway sliding door screen and kitchen screen had rips. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Licensee will ensure that all windows have screens are maintained in good repair. Proof of correction is for licensee to purchase screens or make repairs must be sent by due date. Proof of correction with photos must be sent to ernand.dabuet@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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GOLDEN CARE LIVING IV
FACILITY NUMBER: 198320027
VISIT DATE: 10/08/2024
NARRATIVE
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LPA observed First Aid Kit was maintained. A working landline phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 08/19/24 through 08/19/25. The facility is current with CCLD annual license dues.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted.

An audit of residents #1-#6 (R1-R6) service files and staff #1-#5 (S1-S5) personnel files. The facility has the current administrator's certification on file for Gian Paula Dizon #6071096740 Expiration 07/29/26 and Cheresa Reyes #6004109740 Expiration 11/20/24.

DEFICIENCIES:
  • No window screens for Activity Room and for resident room #2.
  • Window screens require replacement for Hallway and Kitchen.
  • Resident #6 not on hospice care had full extended bed rails without physician's prescription.
  • Obstruction of exit passageway for room #3 with end table furniture.
  • Refilled medications for resident #3 with dementia were stored in a unlocked hall closed accessible to residents in care

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 809-D).

An exit interview conducted with Cheresa Reyes, a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/08/2024 09:33 PM - 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: GOLDEN CARE LIVING IV
FACILITY NUMBER: 198320027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the facility furniture end tables obstructing exit passageways in room #3. This citation poses an immediate health and safety risk to residents in care.
POC Due Date: 10/09/2024
Plan of Correction
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Licensee will adhere to Title 22 regulations to ensure that no exit and passageway are obstructed at all times. The licensee will remove these items and submit correction by POC due date: 10/09/24.
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia - (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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. LPA observed refilled medications for resident #3 dianosed with dementia accessible to resident in care. The medications were store in a closet not in locked cabinet. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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Licensee will adhere to Title 22 Reg 87705 and to ensure that all residents medications are stored in locked storage and not accessible to residents in care at all times. Proof of correction must be sent to LPA Dabuet by POC due date at ernand.dabuet@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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4