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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602400
Report Date: 11/15/2023
Date Signed: 11/15/2023 12:06:39 PM

Document Has Been Signed on 11/15/2023 12:06 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
GREATER LA AC/SC, 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: 5DATE:
11/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Travis Whalen - Program TechnicianTIME COMPLETED:
12:21 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual investigation visit using the CARE inspection tool. LPA met with Travis Whalen an explained the reason for the visit. Administrator arrived 15 minutes later.

The facility is an adult residential licensed to serve a total of six (6) ambulatory adults as a transitional residential program. Facility is a two story home consisting of a living room, kitchen, dining room, activity room, one half bathroom, and an office downstairs. Upstairs there are three bedrooms, two full baths, a laundry room, (2) supply rooms/closets, patio with detached garage.

LPA conducted a tour of the facility with and observed the following:
Home is good repair indoor and outdoor. Each common area is in clean and furniture is in good repair. Facility has a food preparation waiver and meals get prepare in the main house and delivered to the facility. Kitchen is used to store snacks only and facility keeps a container with emergency food supplies is store in the basement. Each bedroom has the required furniture, bedding supplies, and sufficient lighting. Bathrooms (3) are in working condition, water temperature was tested and tested as follow bathroom #1 tested at 123.0 degrees F., and bathroom #2 tested at 116.7 degrees F. which is not within the required 105-120 degrees F. Cleaning supplies are store in a lock closet, and medication is stored in the office in a cabinet with a lock. No large bodies of water were observed in the property. Smoke/Carbon Monoxide detectors were tested and in working condition. Fire extinguishers were observed and last checked on 11/28/22. Last fire drill was conducted on 9/22/23. Emergency Disaster plan was reviewed and does has not been updated to the current version (12/21).
LPA reviewed 5 staff files, 5 client files and medication. Client #5 (C5) is missing a physician's report and TB test results. Clients #1-2 and #4(C1-C2, C4) TB test was administered on 11/14/23 and test results were not read prior admission.
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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 11/15/2023 12:06 PM - It Cannot Be Edited


Created By: Mary G Flores On 11/15/2023 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOODEN RESIDENTIAL WELLNESS CENTER, THE
FACILITY NUMBER: 198602400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in bathroom #1 water temperature tested at 123.0 degrees F. which is not within the required 105 -120 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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Administrator will contact maintenance department who will adjust water heater and will ensure water temperature is within the required 105-120 degrees F. at all times in LIC 9098 and will submit to the department by 11/16/23. Facility will keep a temperature log for the next 7 days and will submit a copy of log by 11/22/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2023 12:06 PM - It Cannot Be Edited


Created By: Mary G Flores On 11/15/2023 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOODEN RESIDENTIAL WELLNESS CENTER, THE
FACILITY NUMBER: 198602400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in emergency disaster plan was not updated to meet the requirements of LIC610 (12/21) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Administrator will provide a copy of LIC 610 (12/21) to the department by POC due date 11/22/23.
Type B
Section Cited
CCR
81069(f)(1)

(f) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/ infectious diseases.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 5 clients do not have results for a TB test examination C1,C2,C4,C5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Administrator will obtain TB test clearance results for C1,C2,C4,C5 and submit a copy to the department by POC due date 11/22/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOODEN RESIDENTIAL WELLNESS CENTER, THE
FACILITY NUMBER: 198602400
VISIT DATE: 11/15/2023
NARRATIVE
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Administrator submitted documents for administrator certificate renewal via mail on 11/7/23.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Cory Mitchell and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC809 (FAS) - (06/04)
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