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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601924
Report Date: 01/19/2022
Date Signed: 01/19/2022 06:46:53 PM

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 IIFACILITY NUMBER:
198601924
ADMINISTRATOR:ANGELIQUE GRADNEYFACILITY TYPE:
740
ADDRESS:1854 EL REY ROADTELEPHONE:
(310) 989-1941
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY:6CENSUS: 5DATE:
01/19/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:52 PM
MET WITH:Catherine Espino TIME COMPLETED:
04:31 PM
NARRATIVE
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On 01/19/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit at this facility and met with the administrator Catherine Espino and explained the purpose of today’s visit is to conduct a plant inspection and health and safety check.

During today's inspection, LPA was conducting a complaint visit, LPA observed non-operational smoke detectors in one (1) location in the living/dining area; a hallway passage through resident rooms and staff room. There are a total of four (4) non-operational smoke detectors. This is a violation of Title 22, Division 6 Chapter 8.

A citation is issued and an exit interview is conducted with Catherine Espino.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
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 2
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 II
FACILITY NUMBER: 198601924
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2022
Section Cited

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and
procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met by evidence:
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Based on observation, the licensee failed to have (4) smoke detectors in operational condition. This violation poses an immediate health and safety risk to residents in care.
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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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2