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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602562
Report Date: 09/05/2024
Date Signed: 09/05/2024 03:31:36 PM

Document Has Been Signed on 09/05/2024 03:31 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/
DIRECTOR:
MITCHELL, CORY BFACILITY TYPE:
772
ADDRESS:146 N HOLLISTON AVETELEPHONE:
(626) 755-0101
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY: 6CENSUS: 5DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:32 PM
MET WITH:Cory Mitchell, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA)s Mary Flores and Mayra Cota conducted an unannounced annual visit at the facility using the CARE inspection tool. LPAs 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.

LPAs toured the facility with Cory Mitchell and observed the following:
Facility is in good repair indoor and outdoor. Living room and dining room were observed with furniture in good repair. Facility has a kitchen which stores dishes, and snacks for the clients. However, all meals are prepared outside the facility and brought into the facility. Facility has a meal preparation waiver. Each client bedroom (3) has the required furniture, bedding supplies, and sufficient lighting. Two bathrooms were observed in good repair and water temperature was tested between 112.3-118.1 degrees F., which is within the required 105-120 degrees F. Medication room is kept lock and there are no sharps or cleaning supplies accessible to the clients. There are no large bodies of water. A shaded outdoor area is available. Fire extinguishers were observed and smoke detectors were tested and are in good repair. First aid kit was observed.
LPAs reviewed medication and files for 5 clients and 5 staff. Facility does not handle P&I for clients.
Administrator certificate was observed for Cory Mitchell #6069942735 Expiration date: 7/29/2026. Infection Control Plan and Emergency Disaster Plan were reviewed.
No deficiencies were noted during this visit. Exit interview was conducted with administrator and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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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