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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603164
Report Date: 05/21/2021
Date Signed: 05/21/2021 01:02:29 PM

Document Has Been Signed on 05/21/2021 01:02 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:GOLDEN HAVEN GUEST HOMEFACILITY NUMBER:
198603164
ADMINISTRATOR:VILLAVERDE, RICHARDFACILITY TYPE:
740
ADDRESS:706 E FOOTHILL BLVDTELEPHONE:
(626) 334-7500
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 15CENSUS: 13DATE:
05/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Martha Guzman & Richard VillaverdeTIME COMPLETED:
01:17 PM
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Licensing Program Analysts (LPAs) David Sicairos and Luis Mora conducted an unannounced annual visit using the Infection Control evaluation tool. LPAs met with Martha Guzman and explained the reason for the visit. Administrator Richard Villaverde arrived shortly thereafter. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

The following were observed/inspected:
  • LPAs and Staff Martha toured the home and inspected (9) resident bedrooms, (2) staff rooms, (3.5) bathrooms, kitchen, dining room, living room, office, storage room, and laundry room. The home consists of (3) three client bedrooms, (2) two bathrooms, office room, living room, dining room, kitchen, and attached garage. The patio area is well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the patio. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and measured at 113.5F, water temperature in bathroom #2 measured at 109.3F which is within the required 105 - 120 degrees. Clients bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Clients beds have the required linen and the linen is in good condition. Each bedroom has a smoke detector which were tested and operable during the visit. There is a carbon monoxide detector located in the hallway and another in the living room area. There is a fire extinguisher located in the kitchen and in the laundry room and they are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and inaccessible to residents. Cleaning supplies and toxins are locked in the office and laundry room and inaccessible to residents. First Aid kits were fully stocked with current manuals.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • (9) out of the (13) resident medications were reviewed. Medications are documented properly and given as prescribed.
  • Staff and Resident files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2021
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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