198602868-6-8-2021-11-AS-LMOA-C3T8CX-20210608222439

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602868
Report Date: 05/28/2021
Date Signed: 06/08/2021 10:27:37 PM

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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	GOLDEN HARVEST CARE HOMES		FACILITY NUMBER:	198602868
ADMINISTRATOR:	TRACY MOORE		FACILITY TYPE:	740
ADDRESS:	11623 CHANERA AVENUE		TELEPHONE:	(323) 305-1839
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY:	6	CENSUS: 5	DATE:	05/28/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	TRACY MOORE		TIME COMPLETED:	12:45 PM

NARRATIVE

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On 5/28/2021 at 9:00 am, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Montoya called Administrator Tracy Moore and conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for 6 non-ambulatory residents and 3 hospice approved waivers for 3 residents. Currently, all 5 residents are over the age of 60, there are 2 non-ambulatory, and 3 ambulatory residents, with one in hospice care residing in the facility.

At 9:10 am, LPA met with the administrator and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked.

The one story residential house consists of (3) resident bedrooms, (2) resident bathrooms, living room, dining room, kitchen,(1) staff bedroom, (1) staff bathroom, and (1) den/office.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, and records of daily Covid-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional 30-day supply of PPE was observed. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the den and the back patio. LPA observed staff and residents maintain 6 feet physical distancing, and all staff wear a face covering. LPA observed required postings throughout the facility.

REPORT CONTINUED IN LIC 809C

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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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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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GOLDEN HARVEST CARE HOMES	FACILITY NUMBER: 198602868
	VISIT DATE: 05/28/2021

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At around 9:30 AM, LPA reviewed the facility’s surveillance testing records, all staff are tested every two weeks. Covid-19 Infection Control and Prevention training records were reviewed. An emergency contact list was reviewed.

All rooms were inspected. Beds in shared bedrooms are 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Furniture in the living room are marked or separated, and 6 feet apart from each other. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. The water temperature measured at 110.0 degrees F in both resident bathrooms. Comfortable temperature was maintained in the facility.

At around 9:45 AM, LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage cabinet. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. The First Aid kit was available. One (1)Carbon Monoxide and five (5)Smoke Detectors (connected) were tested. All alert systems are working properly. The facility (1) Fire Extinguisher was checked and found to be fully charged and accessible.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

The following deficiencies were observed:

1. LPA did not observe printed copies of CDSS PINs. Administrator stated summaries of PINs were not provided to residents/families/responsible parties.
2. License failed to complete the N-95 Fit Testing requirement for all staff.
3. LPA observed the garage was converted into a bedroom with an en-suite bathroom. LPA did not observe a permit and notice to CCLD of the room conversion.

Advisory notes were issued and technical assistance was provided.

A deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Tracy Moore.

An exit interview was conducted, and a copy of this report was provided to Administrator Tracy Moore.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GOLDEN HARVEST CARE HOMES	FACILITY NUMBER: 198602868
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87305(a)

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observaton, the garage was converted into a bedroom with an en-suite bathroom, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2021
	Plan of Correction
1 2 3 4	Licensee agreed to notify CCLD in writing about the alterations made in the facility and will obtain a building permit by the POC due date Licensee will email the letter and building permit to Lourdes.Montoya@dss.ca.gov.

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: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC809 (FAS) - (06/04)

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