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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320174
Report Date: 04/03/2024
Date Signed: 04/03/2024 03:34:47 PM


Document Has Been Signed on 04/03/2024 03:34 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 GROVES RESIDENTIAL CARE LLCFACILITY NUMBER:
198320174
ADMINISTRATOR:GROVES, ANGELAFACILITY TYPE:
740
ADDRESS:2841 GOLDEN AVENUETELEPHONE:
(562) 426-8989
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:6CENSUS: 4DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Caregiver Tana LordTIME COMPLETED:
12:15 PM
NARRATIVE
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On 04/03/24 Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Caregiver Tana Lord as the purpose of the visit was explained. The facility is licensed to serve (6) non-ambulatory of which (1) may be bedridden elderly adults ages 60 and over. There is an approved hospice waiver for (6). Current facility census is (4). Staff provided with upcoming facility fees info ($495). Liability insurance is active with expiration date of 06/19/2024.

The facility is a single-story structure located in a residential neighborhood and consists of the following: (6) resident bedrooms, (3) resident bathrooms, living room, dining room, family room, kitchen, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. Bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to residents, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 2 staff records, 2 resident records, and 2 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 03/05/24, carbon monoxide and smoke detectors are interconnected and operational. (3) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors and windows in the facility have alarm systems.

Deficiencies cited on 809D

Exit interview conducted with, Caregiver Tana Lord appeal rights explained, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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 04/03/2024 03:34 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 GROVES RESIDENTIAL CARE LLC
FACILITY NUMBER: 198320174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review the licensee did not comply with the section cited above employee DP and TL have expired first aid training documentation in employee file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator to enroll staff in first aid training or provide proof of current valid first aid training completion and submit proof to LPA by POC due date.
Type B
Section Cited
CCR
87412(a)(1-10)
87412 Personnel Records


The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee.
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above as there is no LIC 501 or job application for employee (DP) or (TL) in employee file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator to complete LIC 501 or job application for staff and place required documents in employee file and submit proof to LPA by POC due date.
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: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 05/02/2024 01:23 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/23/2024 02:30 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: GOLDEN GROVES RESIDENTIAL CARE LLC
FACILITY NUMBER: 198320174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
87468 Personal rights
At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of:
The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities or and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility.
The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.


This requirement is not met as evidenced by:
Deficient Practice Statement
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This citation has been dismissed.
POC Due Date: 04/17/2024
Plan of Correction
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This citation has been dismissed.
Type B
Section Cited
CCR
87217(b)
87217 Safeguards for Resident Cash, Personal Property, and Valuables
Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources.



This requirement is not met as evidenced by:
Deficient Practice Statement
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This citation has been dismissed.
POC Due Date: 04/17/2024
Plan of Correction
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This citation has been dismissed.
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: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/03/2024 03:34 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 GROVES RESIDENTIAL CARE LLC
FACILITY NUMBER: 198320174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
87458 Medical Assessment
The medical assessment shall include, but not be limited to:
A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility.


Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as here was no documentation of TB test for resident NP in resident file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator to provide proof to LPA of TB test for resident by POC due date.
Type B
Section Cited
CCR
87411(f)
87411Personnel Requirements - General
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.


Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as there was no documentation regarding TB test observed for staff DP in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator to provide LIC 503 with TB test to LPA by POC due date.
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: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4