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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601924
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:44:54 PM


Document Has Been Signed on 03/10/2022 03:44 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
MONTEREY 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:
03/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Kathy Espina, Assistant AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ana Soto and Jeremiah Randle initiated a case management to the above facility. LPA's spoke with Kathy Espina, assistant administrator and the purpose of the visit was explained.

LPA Soto and LPA Randle arrived at the facility and knocked for several minutes without anyone coming to answer the door. LPA Soto called administrator Angelique Gradney and she attempted to call house phone, resident was on the phone so they did not answer. LPA Soto called administrator again after 5 minutes of the initial call to her. She informed LPA Soto that she will call staff personal cell. LPA Soto continued to knock at door and still no answer. LPA's waited outside for 15min without staff answering the door. Finally, a resident came to the door and opened it. He was not sure where the staff was. LPA Soto and LPA Randle entered the facility and looked for the staff. LPA's found staff in the back room helping a resident transfer to their wheel chair. The 2 staff members were assisting the one resident, but they did not hear the LPA's knocking at the front door. The facility does not have a doorbell or any kind of system to alert them someone is in the front door.

An exit interview conducted with Kathy Espina, Assistant Administrator
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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Document Has Been Signed on 03/10/2022 03:44 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
MONTEREY PARK, CA 91754


FACILITY NAME: GOLDEN CARE LIVING II
FACILITY NUMBER: 198601924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2022
Section Cited

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87468.2 -To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This was not met as evidence by:
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Based on observations and interviews staff did not answer the door for about 15 min.
poses a potential 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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