198602868-5-5-2023-11-AS-WGIS-CRK26V-20230505170746

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602868
Report Date: 05/05/2023
Date Signed: 05/05/2023 05:07:51 PM

Document Has Been Signed on 05/05/2023 05:07 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY 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: 6	DATE:	05/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Tracy Moore		TIME COMPLETED:	04:00 PM

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On 05/05/23, Licensing Program Analyst (LPA) Wendy Gibb conducted an unannounced required annual visit using the CARE Inspection Tools. LPA met with Administrator, Tracy Moore and explained the purpose of this visit. The facility is licensed for 6 non-ambulatory residents and 3 hospice approved waivers. Currently, six (6) residents are over the age of 60, they are non-ambulatory resident, with three (3) on hospice care residing in the facility.

Structure The facility is a single-story home in a residential neighborhood. The facility consists of three (3) resident bedrooms, two (2) resident bathrooms, living room, dining room, kitchen, staff room, staff bathroom, and den/office.

Files LPA reviewed six (6) resident files and found the contained all the necessary documentation. LPA reviewed six (6) staff files and found they contained the required documentation, certification, and training (20 hours annually conducted through Relias and assistedlivingeducation.com). LPA reviewed and obtained copies of Client Roster, Staff Roster, Emergency and Disaster Plan (LIC610E), Activity Schedule, Meal Menu, Plan of Operation, Liability Insurance, and Admission Packet with Advertising. Liability Insurance expires on 02/24/2024.

Infection Control During the visit, LPA observed the facility’s infection control practices. LPA was properly screened for Covid-19 symptoms and temperature was checked upon arrival. 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. Visitors are required to show a negative Covid-19 test. If they do not have proof of negative test, facility will test visitors before entering the facility. 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. All staff were wearing a face covering. LPA observed required postings throughout the facility.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN HARVEST CARE HOMES	FACILITY NUMBER: 198602868
	VISIT DATE: 05/05/2023

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Interviews LPA conducted three (3) staff interviews. All staff were able to explain procedures and resident’s personal rights.

LPA did not observe any deficiencies during the time of visit.

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

LPA will return to facility to conduct the tour and medication review at a later date.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

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