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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601924
Report Date: 07/07/2022
Date Signed: 07/10/2022 03:30:16 PM


Document Has Been Signed on 07/10/2022 03:30 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: 4DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Catherine EspinoTIME COMPLETED:
04:00 PM
NARRATIVE
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On 7/7/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Montoya called the facility, spoke with Administrator Angelique Gradney and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. The facility is licensed for six (6) non-ambulatory residents. There are four residents and two caregivers present during the visit. Upon arrival, LPA met with Caregiver Bertin Okezie who assisted with the visit.

LPA Montoya and Caregiver Okezie toured the inside and outside grounds of the facility. At around 1:15 pm, Staff Catherine Espino (Assistant to the Administrator) arrived and joined the visit. LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance and visitors’ log. PPE supplies are readily available to staff, and an additional 30-day supply of PPE; sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation areas are the back patio and dining area. LPA observed staff and residents maintain 6 feet physical distancing, and each staff wears a face covering.

Based on LPA’s record review and interview with Staff Espino, all four residents and all four staff have been vaccinated; N95 Fit testing has been completed and facility staff have been given training on Covid-19 Infection Control and Prevention training. The facility conducts Covid-19 testing for all staff and residents every week.

All rooms were inspected. Beds in shared bedrooms are 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies were in good condition, adequate lighting, and storage for resident personal belongings was observed.

There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, and the shower was free of mold/mildew. A comfortable temperature was maintained in the facility. The water

REPORT CONTINUED IN LIC 809C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
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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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
VISIT DATE: 07/07/2022
NARRATIVE
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temperature is within compliance. All bedrooms, hallway, living room and foyer have working smoke detectors and they are all interconnected and operational. One carbon monoxide detector located in hallway was observed.

LPA toured the kitchen area and the garage. The First Aid kit was available. Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed deficiencies and issued a citation on LIC 9099D.

Exit interview was conducted and a copy of this report and Appeal Rights were provided to Staff Catherine Espino.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/10/2022 03:30 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: 07/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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 as evidenced by:
Deficient Practice Statement
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Based on observation and interview, licensee failed to ensure the facility is in good repair and clean. LPA observed one corner ceiling in the staff bathroom is damaged (stained and torn) due to a water leak; the door of the common bathroom next to the kitchen is not properyly working. LPA had difficulty opening the door; the garage is unorganized and filled with old hospital bed frames, matresses, wheelchairs, commodes, chairs, cabinet, table, empty boxes, television, etc. This poses a potential risk to health, safety and/or personal rights risk to residents in care.

POC Due Date: 07/25/2022
Plan of Correction
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Staff Espino agreed to fix the ceiling, bathroom and organize the garage. Administrator shall email photos of proof of corrections by the POC due date to LPA Montoya (lourdes.montoya@dss.ca.gov).
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA did not observe a skid mat in the bathroom in bedroom # 2. This poses a potential risk to health, safety and/or personal rights risk to residents in care.

POC Due Date: 07/18/2022
Plan of Correction
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Staff Espino agreed to install night lights in the hallway to the nonprivate bathroom. Administrator shall submit photos of the proof of correction by the POC due date to lourdes.montoya@dss.ca.gov.

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) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 07/10/2022 03:30 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: 07/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(7)
Personal Accommodations and Services
(7) Fireplaces and open-faced heaters shall be adequately screened.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed a fireplace (about 20"x50") in size in the living room is not adequately screened. It is blocked with a 4-drawer wooden cabinet (23"x30") and a small red lamp (about 3 feet tall). This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2022
Plan of Correction
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Staff Espino agreed to cover the fireplace with an adequate screen. Administrator shall submit photos of proof of correction to lourdes.montoya@dss.ca.gov by the POC due date.
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed insufficient nonperishable food supply. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2022
Plan of Correction
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Staff Espino agreed to replenish the nonperishable food supply later today. Administrator shall submit a proof of correction to lourdes.montoya@dss.ca.gov by the 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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 07/10/2022 03:30 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: 07/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA did not observe working auditry devices in bedrooms (#1 & #2) where two residents with dementia sleep. This poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2022
Plan of Correction
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Staff Espino agreed to install operable auditory devices in bedroom #1 and #2. Administrator shall submit photos of proof of corrections to lourdes.montoya@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5