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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603006
Report Date: 03/14/2024
Date Signed: 03/14/2024 12:16:45 PM

Document Has Been Signed on 03/14/2024 12:16 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
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: 5DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Maryann Davis - Program TechnicianTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Maryann Davis and explained the reason for the visit.

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 conducted a tour of the facility with Maryann Davis and observed the following:
Facility is in good repair indoor and outdoor. Living room and activity area have sufficient seating area and fire places are inaccessible to clients. Kitchen and dining area were observed clean, snacks were observed, cleaning supplies were observed locked. Facility has a Food delivery waiver, meals are prepared in the main house and delivered to the facility. Each client room (3) has the required furniture, sufficient lighting and bedding supplies. Bathrooms (3) were observed clean, in good repair, and water temperature was tested in each bathroom between 109.2-115.3 degrees F., which is within the required 105-120 degrees F. Medication was observed locked in the medication cabinet. Sharps are not accessible to clients. Smoke/Carbon dioxide detectors were observed, tested, and in working condition. No large bodies of water were observed. Front yard has a porch with seating area, and backyard has a shaded seating area provided. Emergency evacuation chair was not observed. Fire extinguishers were observed and last checked on 11/17/23.
LPA reviewed files and medication for 5 clients and 5 staff files. Client #5(C5) does not have a TB test on file. Emergency Disaster plan was reviewed and last reviewed on 2/3/24. Infection control plan was reviewed. Administrator Certificate for Cory Mitchell was observed #6069942735 exp. 11/14/23.
Deficiencies were noted on LIC 809D per Title 22 Regulations.
Exit interview was conducted with Cory Mitchell 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: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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 03/14/2024 12:16 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/14/2024 at 12:06 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: 03/14/2024

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 C5 does not have a TB clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2024
Plan of Correction
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Administrator will obtain a TB clearance for C5 and submit a copy to the department by POC due date 3/21/24.
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

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 facility does not have an evacuation chair in each stairwell which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Administrator will purchase evacuation chair, will place it by the stairwell, and will submit a picture of evacuation chair by stairwell and a copy of receipt by POC due date 3/28/24.
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: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024


LIC809 (FAS) - (06/04)
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