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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602400
Report Date: 09/28/2022
Date Signed: 09/28/2022 01:58:09 PM

Document Has Been Signed on 09/28/2022 01:58 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GOODEN RESIDENTIAL WELLNESS CENTER, THEFACILITY NUMBER:
198602400
ADMINISTRATOR:MITCHELL, CORY BFACILITY TYPE:
772
ADDRESS:378 N EL MOLINO AVETELEPHONE:
(626) 657-8853
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 6CENSUS: 6DATE:
09/28/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Travis Whalen Program Technician TIME COMPLETED:
02:30 PM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced plan of correction (POC) visit to follow up on deficiencies given on 9/14/22.

On 9/14/22 LPA Flores conducted an annual visit and provided the following deficiencies:

Section 81088(e)(1) Fixtures, Furniture, Equipment, and Supplies. LPA tested water temperature in bathroom #2 water temperature tested at 121.4 degrees F which is not within the required 105-120 degrees F. LPA Flores tested water temperature in bathroom #2 and water tested at 110.6 degrees F., which is within the required 105-120 degrees F. Deficiency cleared on 9/28/22.

Section 81705(b)(6)(D) Health Related Services. LPA Flores reviewed medication for clients and client #1(C1) and #2(C2) had PRN medication. LPA Flores received physician's order request via email on . Deficiency cleared on 9/15/22.

Section 81066(c)(10) Personnel Records. LPA Flores reviewed staff files and staff #2 (S2)and and #3(S3) did not have a health screening on file. LPA Flores received health screening for S2 and S3 via email on . Deficiency cleared on 9/22/22.

Section 81066(c)(11) Personnel Records. LPA Flores reviewed staff files and S3 did not have a TB test clearance on file. LPA Flores received TB test clearance for S3 via email on 9/22/22.

Exit interview was conducted with Travis Whalen Program Technician and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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