198602868-5-20-2024-11-AS-FSHY-D5FQPL-20240520122054

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602868
Report Date: 05/20/2024
Date Signed: 05/20/2024 12:21:04 PM

Document Has Been Signed on 05/20/2024 12:21 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

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:	05/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Tracy Moore, Administrator		TIME COMPLETED:	12:20 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 05/20/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Tracy Moore and explained the purpose of today’s visit. The facility is licensed to serve elderly developmentally disabled residents ages 60 years and older. During the time of visit all three (6) residents were present.

LPA reviewed all resident files and found they contained the required documents. LPA reviewed six (6) staff files and found they contained the required documents, training, and certification. LPA reviewed the trainings for staff. LPA reviewed a copy of the Liability Insurance.

LPA Felisa and Tracy toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (3) client bedrooms, (1) staff room, (2) client bathrooms, (1) staff bathroom, living room, kitchen, dining area, office, patio, washer and dryer located on the service porch, garage used for storage. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedrooms 1-3 are occupied by residents and contain the mandated furniture. LPA observed all rooms to have the required furniture including a beds, nightstands, and chairs. All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley and Tracy toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored in a drawer located in the kitchen. The medications were locked and stored in a cabinet in the kitchen and inaccessible to the resident. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 109.6 degrees Fahrenheit.

Con'd on 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GOLDEN HARVEST CARE HOMES	FACILITY NUMBER: 198602868
	VISIT DATE: 05/20/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The (3) bathrooms have grab bars and are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

LPA Shirley and Tracy walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen. The backyard is clean and clear of obstructions and hazards, shaded patio area and there are no bodies of water present.

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

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

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2