198601924-6-25-2021-11-AS-ASOO-C47RQN-20210621131349

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601924
Report Date: 06/21/2021
Date Signed: 06/25/2021 11:02:46 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
MONTEREY PARK, CA 91754

FACILITY NAME:	GOLDEN CARE LIVING II		FACILITY NUMBER:	198601924
ADMINISTRATOR:	ANGELIQUE GRADNEY		FACILITY TYPE:	740
ADDRESS:	1854 EL REY ROAD		TELEPHONE:	(310) 989-1941
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90732
CAPACITY:	6	CENSUS: 3	DATE:	06/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Patrick Emelogu, House Manager		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required / infection control visit to the above facility. LPA was met by patrick Emelogu, House Manager and later spoke with Angelique Gradney, administrator via telephone and the purpose of today’s visit was explained.

There are currently (3) residents in the facility. (1) residents are ambulatory and (2) are non-ambulatory. The facility is a single story structure located in a residential neighborhood. It consists (4) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room inside the detached 2 garage.

LPA and Patrick toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. The (1) bathrooms are clean and operational 2nd bathroom next to kitchen has a stained shower floor, needs to be cleaned, but it is operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Hallway next to room #4 the ceiling is cracked needs to be repaired. The kitchen ceiling above the oven and cabinet above oven both need cleaning and/or paint. Medications are stored, locked and inaccessible to residents. 1 Resident Medications and file are current. 1 Staff file is missing renewal of CPR/First Aid card. Ample supply of perishable and nonperishable food, hot water temperature is 112 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 1 fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in fair repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged and temperature checked, sanitizer/soap in the staff bathroom and additional sanitation supplies are in a hallway closet. LPA observed staff and residents wearing masks, Room #2 will be converted to isolation room (if needed) and required postings throughout the facility. The residents temperature's are checked and logged once a day. PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Patrick Emelogu, and a hard copy was provided and Appeal Rights.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN CARE LIVING II	FACILITY NUMBER: 198601924
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	87307d2-The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.This requirement was not met as evidence by: Based on kitchen ceiling and cabinet above stove needs cleaning and/or paint. Hallway ceiling has a crack needs repair. Shower #2 next to kitchen needs cleaning an/or paint. Poses health,safety risk for the residents.
	POC Due Date: 07/05/2021
	Plan of Correction
1 2 3 4	Administrator will clean and/or paint kitchen ceiling, cabinet and shower #2. Will repair halway ceiling. Will send pictures of repairs by POC due date by email, fax, and/or mail to LPA Soto

Section Cited


	Deficient Practice Statement
1 2 3 4	87411c1-All RCFE staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter.Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This reqirement was not met as evidence by: Based on CPR/Fisrt Aid card expired 02/21 for 1 staff.
	POC Due Date: 07/05/2021
	Plan of Correction
1 2 3 4	Administrator to provide a renewal picture for Staff #1 CPR/Fisrt Aid card by POC due date by email, fax, and/or mail to LPA Soto.

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC809 (FAS) - (06/04)

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