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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603006
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:16:36 PM

Document Has Been Signed on 04/13/2022 03:16 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: 3DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:Vanessa Mendez - House Director TIME COMPLETED:
03:30 PM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual investigation at the above facility with focus on infection control domain, medication and food review. LPA Flores met with Vanessa Mendez House Director and explained the reason for the visit.

Facility is licensed as a Social Rehabilitation Facility to serve 6 ambulatory clients. The facility is in a residential area and has 3 client bedrooms, 3 bathrooms, a staff bathroom, a kitchen, a living room, an activity room, a laundry room in the basement, a front porch, and a back yard. No large bodies of water were observed. Smoke detectors/Carbon Monoxide detectors were observed and tested.

LPA Flores conducted a tour of the facility with Vanessa Mendez House Director:
Facility has a meal delivery plan on file, does not prepare meals on site and receives meals delivered from the main house. No sharps were observed. Cleaning and PPE supplies were observed in kitchen closet and maintain lock. All bedrooms have lighting, all required bedding and furniture. Bathrooms have sufficient soap, water temperature was tested in bathroom #1(B1) at 109.0 degrees F., bathroom #2(B2) tested at 118.2 degrees F., and bathroom #3(B3) tested at 117.8 degrees F., paper towels were not observed in B2, B3. Staff bathroom did not have paper towels and hand washing sign. Medications are kept in a closet across from staff bathroom. LPA reviewed medication and files for client #1(C1),#2(C2),#3(C3), LPA observed C1,C2 and C3 had supplements with no labels and or physician's order. Files were reviewed for staff #1,#2,#3.

Facility is currently not following infection control guidelines. Technical Advisories have been given during this visit.

No deficiencies under Title 22. Exit interview was conducted with Vanessa Mendez House Director and a copy of this report and technical advisories have been provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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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Document Has Been Signed on 04/13/2022 03:16 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/13/2022 at 02:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOODEN RESIDENTIAL WELLNESS CENTER #4, THE
FACILITY NUMBER: 198603006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81075(b)(6)(D)
Health - Related Services: For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated, written order from a physician on a prescription blank, maintain in the client's file, and a label on the medication...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA Flores reviewed medication and observed vitamin B12, vitamin D without a prescription for C1 and Probiotics, Omega 2, Vitamin E, Vitamin D, Magnesium for C2, and Tumerica and Gas Relief for C3 each without labels which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2022
Plan of Correction
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Licensee will obtain Physician's order for the supplements listed for C1,C2, and C3 and submit a copy to the deparment by 4/20/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


LIC809 (FAS) - (06/04)
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