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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603006
Report Date: 04/27/2023
Date Signed: 04/27/2023 04:09:31 PM

Document Has Been Signed on 04/27/2023 04:09 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
GREATER LA AC/SC, 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:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Sarah Canizales - Program Technician TIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Sarah Canizales Program Technician. Administrator Cory Mitchell arrived 20 minutes later.

Facility is licensed as a Social Rehabilitation Facility to serve 6 ambulatory clients. The facility is a two story home located in a residential area and consist of 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.

LPA Flores conducted a tour of the facility with Sarah Canizales and observed the following:
Facility is clean, and in good repair inside and out. Living room, and activity room were observed to have sufficient sitting area. Kitchen was observed to store snacks for each client as the facility obtains their meals from the main kitchen. The facility has a food/meal serving waiver as part of their plan of operation. Cleaning and hygiene supplies were observed locked in a kitchen closet. Medication and sharp objects were observed locked in a closet across from staff bathroom. Each client room was observed and provides sufficient lighting, bedding supplies, and the required furniture. Each room has a bathroom in working condition and water temperature was tested between 125.4 - 130.6 degrees F., which is not within the required 105-120 degrees F.
Smoke detectors/Carbon Monoxide detectors were observed, tested, and are in working condition. Fire extinguishers were observed and last checked on 11/28/22. A fire drill was conducted on 4/23/23. No large bodies of water were observed. Backyard and front porch has shaded sitting areas.
LPA Flores reviewed files and medication for 5 clients and 5 staff files. Medications for client #4(C4) were observed without a label. During file review all 5 clients were missing a TB test clearance. Administrator certificate for Cory Mitchell needs to be renew. LPA conducted interviews with 2 staff and 2 clients.
Deficiencies were noted per Title 22 Regulations on LIC 809D.
Exit interview was conducted with Cory Mitchell administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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 5
Document Has Been Signed on 04/27/2023 04:09 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/27/2023 at 03:29 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: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 bathroom #1 water temperature was tested at 130.6 degrees F., bathroom #2 water temperature was tested at 125.4 degrees F., and bathroom #3 water temperature was tested at 128.4 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Administrator will certify on LIC 9098 that will ensure water temperature is maintain within the required 105-120 degrees F. by POC due date 4/28/23 and will submit a temperature log for each bathroom for the next 7 days.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/27/2023 04:09 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/27/2023 at 03:29 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: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81069(f)(1)
Client Medical Assessments
(f) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/ infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 clients did not have a TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
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Administrator will obtain a TB test clearance for each client and will submit a copy to the department by POC due date 5/4/23.
Type B
Section Cited
CCR
81075(k)(3)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (3) All medications shall be labeled and maintained in compliance with label instructions and state and federal laws.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out 5 client's medication reviewed had 2 medications without a label which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
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Administrator will ensure all medication is label and obtain the medication with a label and submit a picture to the department by POC due date 5/4/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/27/2023 04:09 PM - It Cannot Be Edited


Created By: Mary G Flores On 04/27/2023 at 03:29 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: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in disaster plan reviewed did not have the information pertaining Title 22 regulations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
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Administrator will update Emergency Disaster Plan or fill out LIC 610D Emergency disaster plan and submit a copy to the department by POC due date 5/4/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5