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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602562
Report Date: 09/26/2023
Date Signed: 09/26/2023 12:01:05 PM

Document Has Been Signed on 09/26/2023 12:01 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 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: 3DATE:
09/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Cory Mitchell - Administrator TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Cory Mitchell and explained the reason for the visit.

The facility is licensed to served 6 ambulatory adults between the ages of 18 - 59 years old, and serves as a Transitional Rehabilitation Program. The facility is a two floor structural home located at the back of a community of single homes. It consist of 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 toured the facility with Cory Mitchell and observed the following:
Facility is in good repair inside and outside. There is an outdoor shaded area in front of the house, no large bodies of water were observed. Living room has sufficient sitting area and cabinets store activities. Each client' bedroom has sufficient lighting, furniture and bedding supplies. Bathrooms(2) are in working condition and water was tested between 116.3 - 120.0 degrees F., which is within the required 105 -120 degrees F. Smoke/Carbon monoxide detectors were observed, tested, and in working condition. Dining/living area on the second floor were observed clean and in good repair. Fire extinguishers were observed and last checked on 11/28/22.

LPA reviewed medication and flies for 3 clients and 5 staff files. Client #2(C2) does not have a TB clearance on file. Emergency disaster plan was reviewed. Last fire drill was conducted on 9/16/23.

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: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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 4
Document Has Been Signed on 09/26/2023 12:01 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/26/2023 at 11:20 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: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81091(a)(2)
Prohibited Health Conditions
(a) Clients who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained. (2) Active, communicable TB.

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 1 out 3 clients, C2 does not have a TB clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2023
Plan of Correction
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Administrator will ensure C2 obtains a TB test clearance and submit a copy to the department by POC due date 10/3/23.
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: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


LIC809 (FAS) - (06/04)
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