198603164-5-13-2022-28-AS-NMAN-CEDUHN-20220513153612

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603164
Report Date: 05/13/2022
Date Signed: 05/13/2022 03:37:49 PM

Document Has Been Signed on 05/13/2022 03:37 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 HOME		FACILITY NUMBER:	198603164
ADMINISTRATOR:	VILLAVERDE, RICHARD		FACILITY TYPE:	740
ADDRESS:	706 E FOOTHILL BLVD		TELEPHONE:	(626) 334-7500
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY: 15		CENSUS: 11	DATE:	05/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Staff Martha Guzman		TIME COMPLETED:	03:45 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Nune Margaryan and Ya Ting Yang conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPAs met with Staff Martha Guzman and explained the reason for the visit. Physical Plant was toured, residents files and medication records were reviewed, staffs files records reviewed and food supply was inspected. The facility is licensed for fifteen (15) residents over the age of 60.

The facility is a single story building. LPAs toured the home and inspected nine(9)resident bedrooms, two(2) staff rooms 3.5 bathrooms, kitchen, dining room, living room, office, storage room, and laundry room. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located at the entrance of facility. Sign in sheet, hand sanitizer, gloves and masks are available. Staff conducted a routine symptom screening of LPAs at the time of entrance and have a sign-in policy as required per COVID-19 procedures. All staff were observed to be wearing mask during this visit.

LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways are free of obstruction.

LPAs toured residents rooms. All bedrooms were furnished with required furniture. The bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. The hot water was between 110.6 to 111.3 degrees which is within the required 105 - 120 degrees. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. At the time of inspection LPAs observed chemicals and cleaning supplies under the sink and cooking knifes in drawer next to the stove unlocked and assessable to residents.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 198603164
	VISIT DATE: 05/13/2022

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LPAs observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. The facility has a sprinkler system with wired alarm. 3 fire extinguishers are present in the facility and are fully charged. LPAs observed the facility had the required carbon monoxide detectors.

LPA reviewed 5 residents and 2 staff records. Residents' records were found to be complete and current. Staff files were reviewed, and documentation noted that facility staff maintain a criminal record clearance and associated to the facility. LPA randomly chose some residents' medications to review. Medications are documented properly and stored appropriately.

Deficiencies have been noted on LIC 809D under Title 22 Regulations.

Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Martha Guzman.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/13/2022 03:37 PM - It Cannot Be Edited

Created By: Nune Margaryan On 05/13/2022 at 03:07 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: GOLDEN HAVEN GUEST HOME	FACILITY NUMBER: 198603164
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)(2)

Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).(2)Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation LPAs observed chemicals and cleaning supplies under the sink and cooking knifes in drawer next to the stove unlocked and assessable to residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2022
	Plan of Correction
1 2 3 4	Staff removed the items during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Wei Siew Ho

LICENSING EVALUATOR NAME:

Nune Margaryan

LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

LIC809 (FAS) - (06/04)

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