198603006-4-3-2025-28-AS-MGFS-DFDQ45-20250403114947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603006
Report Date: 04/03/2025
Date Signed: 04/03/2025 11:50:08 AM

Document Has Been Signed on 04/03/2025 11:50 AM - 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, THE		FACILITY NUMBER:	198603006
ADMINISTRATOR/ DIRECTOR:	MITCHELL, CORY B		FACILITY TYPE:	772
ADDRESS:	539 N LOS ROBLES		TELEPHONE:	(626) 755-3021
CITY:	PASADENA	STATE: CA	ZIP CODE:	91101
CAPACITY: 6		CENSUS: 4	DATE:	04/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:02 AM
MET WITH:	Maryann Davis - Program Technician		TIME VISIT/ INSPECTION COMPLETED:	12:00 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	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, a detached garage, and a back yard. The following CARE tool domains were reviewed during this visit: Infection Control: Facility maintains an infection control plan. Hand sanitizing and infection prevention were observed at the facility. A responsible person was available at the facility. Physical Plant & Environmental Safety: LPA toured the facility with Maryann Davis and Cory Mitchell and observed the facility is mostly in good repair indoor and outdoor. Kitchen was observed clean. Cleaning supplies and sharps were observed locked in storage cabinets. Living room and activity room were observed with sufficient furniture each have a fireplace that are not currently working. Stairways are cleared. LPA observed (3) shared client bedrooms with sufficient lighting, furniture, and bedding supplies. Three (3) bathrooms were observed in good repair and water temperature was tested between 106.5 - 108.1 degrees F., which is within the required 105-120 degrees F. Ceiling in bathroom #1 was observed with wallpaper peeling. Smoke detectors were tested and in working condition. Laundry area is located in the basement. Front porch and backyard offer shaded seating area for the client. Garage is not accessible to the clients. Passageways and exit areas were observed free of obstructions. No large bodies of water were observed. Back porch fence was observed with paint peeling. (CONTINUED ON LIC 809C)

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, THE	FACILITY NUMBER: 198603006
	VISIT DATE: 04/03/2025

NARRATIVE

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Operational Requirements: Client's records of personal belongings was reviewed. Supervision is available at all times. Currently there are no clients that required accommodations.
Staffing: Two staff were observed during the visit. A consultant was providing an activity and staff are available on call at all times. Facility does not vendorize with the Regional Center.
Personnel Records - Training: All staff records were available for review. Each staff has a criminal background clearance. There is an assigned Administrator who has completed training. Administrator certificate was observed for Cory Mitchell #6069942735 exp. date: 7/29/26. Five staff files were reviewed which include health screenings, TB test clearance, personnel records, finger clearance, and yearly training.
Client Records - Incident Reports: All client records were available for review. Files were reviewed for 5 clients, which included medical assessments, admission agreement, individual service plan or needs and care plan, and TB test. 1 out of 5 clients did not have a TB test clearance on file. One client was admitted on 4/1/25 and will obtain a medical assessment and TB test within the 72 hour from admission.
Client Rights - Information: Clients rights were observed posted in the activity areas. A device with internet access is available upon request.
Food Service: Facility has a Meal preparation waiver and meals are delivered by their main kitchen three times a day. Facility maintains snacks and preferences on site. There are no clients with modified diets.
Health-Related Services: All clients at the facility are ambulatory. Medication were observed centrally stored. A staff assist clients with medication and PRN medications. There is a log to track PRN medication intake. Staff have a current First Aid/CPR training on file and are responsible for contacting emergency services. Facility maintains a plan per client to assist with their care and supervision.
Incidental Medical Services: Facility does not currently serve any clients with restricted health conditions.
Disaster Preparedness: Emergency Disaster Plan LIC610D (12/21) was observed and last reviewed on 2/5/25. Last emergency drill was conducted on 3/31/25 and are conducted quarterly. Evacuation chairs were observed. Emergency food supplies were observed in the basement.

LPA interviewed 2 clients and 2 staff.

A Technical violations were noted. No deficiencies were noted during this visit.

Exit interview was conducted with Cory Mitchell and technical violation was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC809 (FAS) - (06/04)

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