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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602562
Report Date: 10/20/2022
Date Signed: 10/20/2022 02:20:39 PM

Document Has Been Signed on 10/20/2022 02:20 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, THEFACILITY NUMBER:
198602562
ADMINISTRATOR:MITCHELL, CORY BFACILITY TYPE:
772
ADDRESS:146 N HOLLISTON AVETELEPHONE:
(626) 755-0101
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY: 6CENSUS: 6DATE:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Anthony Ramos - Staff
Cory Mitchell - Director of Compliance 		TIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, food, and medication review. LPA met with Anthony Ramos facility staff and explained the reason for the visit. Cory Mitchell Director of Compliance arrived 15 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 Flores and Anthony Ramos staff conducted a tour of the facility and observed the following:
Facility maintains all cleaning supplies, sharps, and medication locked in program technician office. Meals are deliver to the facility from main home per their plan of operation. Facility's kitchen stores sufficient snacks for clients. Kitchen and dining area floors and furniture were observed with dust, crumbs, and stains. All bedrooms have the required furniture, bedding, and sufficient lighting. Bedroom #2(R2) has two holes of about the size of a quarter each next to the air condition fixture and the air condition is missing temperature control knob. Smoke detector/carbon monoxide detectors were tested and are in working condition. Fire Extinguishers were last service on 3/10/22. Medication and files were reviewed for 3 clients, client #3(C3) does not have a TB test clearance on file and PRN medication was observed that does not have a physician's order. Files for 2 staff were reviewed.

Deficiencies noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Cory Mitchell Director of Compliance and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
Document Has Been Signed on 10/20/2022 02:20 PM - It Cannot Be Edited


Created By: Mary G Flores On 10/20/2022 at 01:59 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: 10/20/2022

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
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Based on observation, the licensee did not comply with the section cited above in bedroom #2(R2) has 2 holes of about the size of a quarter in the wall next to the a/c fixture, a/c is missing temperature knob in R2, and kitchen's, dining room floors and furniture were observed with dust, crumb,and stains which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2022
Plan of Correction
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Licensee is to repair the holes, replace the knob, and ensure facility is clean at all times and will submit pictures to the department by POC due date 11/3/22.
Type B
Section Cited
CCR
81069(f)(1)
Client Medical Assessments
(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 observation and documents review, the licensee did not comply with the section cited above in 1 out of 3 clients files review does not have a TB test clearance on file, client #3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2022
Plan of Correction
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Licensee is to submit proof of TB test clearance to the department by POC due date 11/3/22.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 10/20/2022 02:20 PM - It Cannot Be Edited


Created By: Mary G Flores On 10/20/2022 at 01:59 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: 10/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

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 1 out of 3 clients medication review Client #3 PRN medication does not have a physician's order which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2022
Plan of Correction
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Licensee will submit physician's order for PRN medication to the department by POC due date 11/3/22.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022


LIC809 (FAS) - (06/04)
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