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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603006
Report Date: 12/22/2021
Date Signed: 12/22/2021 02:14:51 PM

Document Has Been Signed on 12/22/2021 02:14 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GOODEN RESIDENTIAL WELLNESS CENTER #4, THEFACILITY NUMBER:
198603006
ADMINISTRATOR:MITCHELL, CORY BFACILITY TYPE:
772
ADDRESS:539 N LOS ROBLESTELEPHONE:
(626) 755-3021
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 6CENSUS: 6DATE:
12/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator Cory Mitchell and Chief Information Officer Phil WilkinsTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Jose Villalobos made and unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Administrator Cory Mitchell and Chief Information Officer Phil Wilkins and the purpose of the visit was discussed.

As a part of the inspection, LPA used the inspection tool, reviewed (3) staff files, (6) client records and medications. The facility is a Social Rehabilitation Facility that currently has (6) clients which are ambulatory. There were three (3) bedrooms designated for (2) clients each. All required furnishings were present and there were sufficient supplies of bedding and linens present. There were three and a half (3 1/2) bathrooms. All fixtures appeared clean and functional. The three (3) full bathrooms are for client use and each attached to a bedroom. Facility has living room, TV room, group room and dining area (attached to the kitchen). All common areas were furnished appropriately to accommodate a maximum capacity of six (6). Kitchen appliances and fixtures appeared clean and functional. Water temperature within Title 22 regulation. Food supply was observed. Knives and Sharps observed to be locked and inaccessible to clients. Laundry equipment is located in the basement and is kept inaccessible by clients except with supervision. These include both front and back porches, lawns, gardens, a patio, shaded areas and furniture appropriate for outdoor use. There is a tool shed that is kept inaccessible to clients. Required infection control signs observed throughout the facility.

Infection control domain completed and there were no deficiencies. An exit interview was conducted and copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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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