198603164-5-11-2023-28-AS-ALOZ-CRQUEG-20230511153106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603164
Report Date: 05/11/2023
Date Signed: 05/11/2023 03:31:25 PM

Document Has Been Signed on 05/11/2023 03:31 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:	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: 15	DATE:	05/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:54 AM
MET WITH:	Martha Guzman, Richard VillaVerde		TIME COMPLETED:	03:44 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 Analysts (LPAs) Alberto Lopez conducted an unannounced annual visit using the Care Evaluation Tool. LPA met with Staff Martha Guzman and explained the reason for the visit. Administrator Richard Villaverde joined LPA later and assisted with the visit. Physical Plant was toured. 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. Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has Infection control plan at facility. Physical Plant & Environment Safety: . There are 9 client bedrooms, 6 shared rooms 3.5 bathrooms, 3 with showers, living room, activity room, dining room, kitchen, laundry room. Facility has operable smoke and carbon monoxide combo detectors located in hallway and was tested. Knives, cleaning solutions, and disinfectants are locked in the cabinets. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms and kitchen sink. The hot water temperature in measured 109.4 – 109.5 degrees F which is within the required range of 105-120 degrees F. Facility roof is in need of replacement. Operational Requirements The licensee provides care and supervision as required. Plan of operation was at facility for inspection. Staffing: There appears to be sufficient staffing at the facility. The administrator’s certificate expires 06/09/2023 Staff employed are all over the age of 18. Planned Activities: Facility staff encourage residents to participate in activities.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

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 6

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: GOLDEN HAVEN GUEST HOME	FACILITY NUMBER: 198603164
	VISIT DATE: 05/11/2023

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
26
27
28
29
30
31
32

Resident Rights/Information: Resident rights are posted at facility and staff are familiar with resident rights.
Personnel Records-Training: Staff files are maintained at the facility. All staff have current CPR first aid training. Facility has documentation on file that verify CPR for all staff.
Residents Records-Information: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, pre-admission assessment and other required documentation.
Food Service: There are sufficient food supplies of 2-day perishable and a week (7 days) of non-perishable items. The food is properly stored in the refrigerator to avoid cross contamination.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed 5 client’s medication and medication is administered following physician’s orders. PRN letters were not on file.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last emergency drill 4/27/2023
Residents with Special Health Needs: Facility accepts and retains residents with special health needs.

During the visit today, LPA did observed deficiency at time of visit. See 809D. Technical advisories were provided. An exit interview was held. A copy of this report, technical advisory notes, and appeal rights were given to Licensee Richard Villaverde

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 05/11/2023 03:31 PM - It Cannot Be Edited

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: GOLDEN HAVEN GUEST HOME	FACILITY NUMBER: 198603164
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above. Roof is in need of replacement and there was indications that it is leaking in the laundry room. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2023
	Plan of Correction
1 2 3 4	Licensee will replace roof and fix any leaks by POC date and send proof to LPA.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6