198602562-9-30-2021-28-AS-MGFS-C7CRKL-20210930130543

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602562
Report Date: 09/30/2021
Date Signed: 09/30/2021 01:06:05 PM

Document Has Been Signed on 09/30/2021 01:06 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GOODEN RES WELLNESS CENTER AT HOLLISTON CT, THE		FACILITY NUMBER:	198602562
ADMINISTRATOR:	MITCHELL, CORY B		FACILITY TYPE:	772
ADDRESS:	146 N HOLLISTON AVE		TELEPHONE:	(626) 755-0101
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY: 6		CENSUS: 3	DATE:	09/30/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:34 AM
MET WITH:	Phil Wilkens - Chief Information Officer George Ricciardella - Director Development		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit with focus on the infection control domain, food and medication review. LPA met with George Ricciardella Director Development and explained the reason for the visit. Phil Wilkens Chief Information Officer arrived 30 minutes later . The facility is a two floor structural home located at the back of a community of single homes. The facility is licensed to served 6 ambulatory adults between the ages of 18 - 59 years old. The facility serves as a Transitional Rehabilitation Program. There is an outdoor shaded area in the front, there are no large bodies of water, facility has 3 client rooms, 2 client bathrooms, a living room down stairs and upstairs, kitchen and dinning room are located in the 2nd floor, a therapist office upstairs and downstairs, a program technician office downstairs, and a case management office in the 2nd floor. LPA observed all common spaces in good repair and clean. Bedroom #1(R1) has a built in drawer in bed missing, bedroom #2(R2) does not have sufficient lighting and built in drawer under bed broken, built in drawers in beds are used as chest drawers for clients storage. Bathroom #1(B1) has rust build up in shower hose ring, no sufficient lighting, and water temperature was tested at 123.1 degrees F; bathroom #2's(B2) shower tub paint has a peel patch of about 6 inches long and 3 inches wide and water temperature was tested at 77.5 degrees F which are not under the recommended temperature of 105 - 120 degrees F . Facility's kitchen maintains snacks and dishes only, client's 3 meals per day get prepared at main house and delivered at the facility per meals schedule, LPA observed a digital meal tracker that is maintain. Facility maintains medication, knives, and cleaning/disinfecting supplies in the program technician office which is locked at all times and accessible to staff only. Fire extinguishers are located outside the building in glass cases and up to date. Smoke/Carbon monoxide detectors were observed and tested throughout the facility . LPA reviewed medication for client #1(C1) and client #2(C2). COVID 19 recommendations are being followed regarding screening, isolation procedures, and training. (CONTNUED ON LIC (9099C)

SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

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 09/30/2021 01:06 PM - It Cannot Be Edited

Created By: Mary G Flores On 09/30/2021 at 11:54 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 RES WELLNESS CENTER AT HOLLISTON CT, THE	FACILITY NUMBER: 198602562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81087(a)

Buildings and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 3 built in drawers in bed drawers for client personal storage in R1 drawer was broken in R2 drawer was missing, B2 shower tub is in disrepair, and B1 shower hose ring had rust build up which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2021
	Plan of Correction
1 2 3 4	Licensee will repair drawer in R2, and LPA was email repair order for drawer in R1 and will ensure that facility has sufficient furniture and in good repair and will submit pictures to the department by 10/14/21.

Type B

Section Cited

CCR

81088(i)(2)

Fixtures, Furniture, Equipment, and Supplies

(i) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) In addition to subsection (c)(1) above, each client shall have a chair, a night stand, and a lamp or lights necessary for reading. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in providing sufficient lighting in B1 and R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2021
	Plan of Correction
1 2 3 4	Licensee will ensure facility provides sufficient lighting throughout the facility at all times and will ensure there is lighting in B1 and R2 will submit pictures to the department by 10/14/21.

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:

Rebecca Orendain

LICENSING EVALUATOR NAME:

Mary G Flores

LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC809 (FAS) - (06/04)

Page: 2 of 8

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOODEN RES WELLNESS CENTER AT HOLLISTON CT, THE	FACILITY NUMBER: 198602562
	VISIT DATE: 09/30/2021

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Facility has sufficient PPE supplies for at least 30 days. Facility will ensure there are hand washing signs next to each available sink at the facility and cough/sneeze etiquette signs in the common areas. Facility will ensure staff that may be exposed to COVID 19 at the facility get Fit Test for N95 mask. Facility will ensure hand sanitizer is maintain available in common areas.

Deficiencies will cited under Title 22 Regulations on LIC 809D and technical advisories will be given.

Exit interview was conducted with Phil Wilkens and a copy of this report, LIC 809D, technical advisory notes, and appeal rights were provided.

SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC809 (FAS) - (06/04)

Page: 7 of 8

Document Has Been Signed on 09/30/2021 01:06 PM - It Cannot Be Edited

Created By: Mary G Flores On 09/30/2021 at 12:15 PM

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 RES WELLNESS CENTER AT HOLLISTON CT, THE	FACILITY NUMBER: 198602562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

81088(a)(1)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as water temperature in B1 tested at 123.1 degrees F and B2 at 77.5 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/01/2021
	Plan of Correction
1 2 3 4	Licensee will ensure facility's water temperature is maintain within the required range of 105 - 120 degrees F, will submit LIC 9098 to certify by 10/1/21 and will maintain a water temperature log for the next 7 days which will be submitted to the department by 10/7/21.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Rebecca Orendain

LICENSING EVALUATOR NAME:

Mary G Flores

LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC809 (FAS) - (06/04)

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