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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602868
Report Date: 06/16/2021
Date Signed: 06/17/2021 10:39:54 AM

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 HOMESFACILITY NUMBER:
198602868
ADMINISTRATOR:TRACY MOOREFACILITY TYPE:
740
ADDRESS:11623 CHANERA AVENUETELEPHONE:
(323) 305-1839
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:6CENSUS: 4DATE:
06/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:TRACY MOORETIME COMPLETED:
02:45 PM
NARRATIVE
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On 6/16/2021 at 12:48 pm, Licensing Program Analyst (LPA) Lourdes Montoya and Licensing Program Manager (LPM) Angela Kendrick conducted an unannounced case management visit at the above facility to address deficiencies observed during the annual inspection visit on 5/28/2021. 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.

During LPA’s tour of the facility on 5/28/2021, LPA observed the following:

* A den was turned into a resident bedroom with two beds and a male resident was observed in the bedroom


* An exit security door next to the service room was locked. The exit ramp was converted into a utility room. LPA observed utility items such as broom, pail, cardboard box, black bin and mops in the utility room.

At around 1:05 pm, LPA and LPM toured the inside and outside grounds of the facility with Administrator Tracy Moore. Moore stated the male resident who was staying in the den was a respite resident and has already left the facility. Moore stated that the exit door next to the service room was approved by the fire marshal to be taken off as an exit. Moore stated she revised the sketch by removing the exit doors next to the service room and inside the den. LPA and LPM did not observe a written approval from the fire marshal of these changes.

Based on LPA’s and LPM’s observations and interview with Administrator Moore, the following deficiencies have been determined:


1. An exit security door next to the service room was locked. The exit ramp was converted into a utility room. LPA and LPM observed and took photos of utility items such as a broom, pail, cardboard box, black bin and mops.

2. A den next to the family room was converted into a resident bedroom.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, deficiencies were cited (Refer to LIC 809-D). Appeal Rights Discussed. An exit interview was conducted, and a copy of this report was provided to Licensee/Administrator Tracy Moore.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
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 2
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: 06/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/22/2021
Section Cited

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 No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed, or similar detached building.

This was not met as evidenced by:
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Based on LPA Montoya's and LPM Kendrick's observation and interview with the Administrator, the den next to the family room was converted into a resident bedroom. A male respite resident stayed in this room for a limited number of days. This poses a potential risk to the health, safety and personal rights to residents in care.
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Type B
06/22/2021
Section Cited

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(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This was not met as evidenced by:
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Based on LPA's and LPM's observation, the exit door next to service room was locked and the exit ramp was converted into a utilty room. Utility items such as broom, mops, pail, black bin, cardboard box were stored in the exit ramp. This poses a potential risk to the health, safety and personal rights to residents in care.
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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: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021
LIC809 (FAS) - (06/04)
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