198603164-5-9-2024-28-AS-CGUZ-D54SJW-20240509135549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603164
Report Date: 05/09/2024
Date Signed: 05/09/2024 01:56:02 PM

Document Has Been Signed on 05/09/2024 01:56 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
MONTEREY PARK ASC, 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: 10	DATE:	05/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:56 AM
MET WITH:	ADMINISTRATOR RICHARD VILLAVERDE		TIME COMPLETED:	10:57 AM

NARRATIVE

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Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Administrator Richard Villaverde and explained the reason for the visit. Physical Plant was toured.

The facility is licensed for fifteen (15) residents over the age of 60 of which 10 may be non-ambulatory. 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.

LPA Gutierrez conducted a tour of the facility, reviewed records, and interviewed 2 staff and 1 client. The following were observed: Client bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen. Each bedroom has a smoke detector which were tested bedroom #9 was observed not working technical violation (TV) was given Administrator replaced smoke detector at time of visit. There is a carbon monoxide detector located in the hallway and another in the living room area. The bathrooms were observed to be clean and equipped with grab bars and non-skid mats. Bathroom #1 was observed to have a leak under sink when hot water was turned on. The hot water was between 106.6 to 115.3 degrees which is within the required 105 - 120 degrees. There is a fire extinguisher located in the kitchen and in the laundry room and they are fully charged. Sharps are locked in the kitchen and inaccessible to residents. Cleaning supplies and toxins are locked in laundry room and inaccessible to residents. First Aid kits were fully stocked with current manuals. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the back patio. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian Gutierrez	TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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 05/09/2024 01:56 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
MONTEREY PARK ASC, 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: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(6)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. 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 in ONE (1) of THREE(3) bathrooms had a leak under sink when hot water was turned on which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2024
	Plan of Correction
1 2 3 4	Fix leak under sink submit proof with recipt from plumber or handy man.

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian Gutierrez	TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN HAVEN GUEST HOME	FACILITY NUMBER: 198603164
	VISIT DATE: 05/09/2024

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Three (3) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Five (5) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in April of 2024. Infectious control plan was reviewed. Two (2) staff and (1) client was interviewed. Five (5) out of (5) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

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 Richard Villaverde.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian Gutierrez	TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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