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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601924
Report Date: 02/24/2022
Date Signed: 02/24/2022 11:57:11 PM


Document Has Been Signed on 02/24/2022 11:57 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
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: 4DATE:
02/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Catherine Espino TIME COMPLETED:
03:01 PM
NARRATIVE
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On 02/24/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA was greeted by administrator Catherine Espino and explained the purpose of the visit. LPA was at this facility in conjunction with complaint #11-AS-20220113160924.

During the visit LPA was made aware the facility failed to adhere to regulations Title 22 Section 87355. LPA identified and confirmed staff #1 (S1) worked at this facility on 02/23/22 and 02/24/22 caring for residents without proof of criminal clearance background check. Espino sent staff home and stated staff will not return to work until she has obtained a California Clearance or a Criminal Record Exemption as required by (CCLD) Community Care Licensing Division.

Based on the information gathered, the licensee violated the California Code Regulations (CCR) of Title 22 sections 87355 Division 6 Chapter 8.

Citation is issued, civil penalties assessed, and exit interview 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: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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


Document Has Been Signed on 02/24/2022 11:57 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
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: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2022
Section Cited

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Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility. (1) Obtain a California clearance or a criminal record exemption as required by the Department.
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This requirement is not met as evidenced by:
During the visit conducted on 02/24/22, LPA verified that (S1) Penny Tan was employed and worked at this facility prior to obtaining a California clearance or a criminal record exemption as required by the CCLD.
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A civil penalty in the amount of $200.00 was issued.

Citation was cleared during visit 02/24/22.

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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: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
LIC809 (FAS) - (06/04)
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