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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603164
Report Date: 04/22/2025
Date Signed: 04/22/2025 02:37:25 PM

Document Has Been Signed on 04/22/2025 02:37 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 HOMEFACILITY NUMBER:
198603164
ADMINISTRATOR/
DIRECTOR:		VILLAVERDE, RICHARDFACILITY TYPE:
740
ADDRESS:706 E FOOTHILL BLVDTELEPHONE:
(626) 334-7500
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 15CENSUS: 10DATE:
04/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Richard Villaverde, Administrator
Martha Guzman, Staff		TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Nune Margaryan and Blanca Gonzalez conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPAs met with Richard Villaverde, Administrator and explained the reason for the visit. Physical Plant was toured, residents files and medication records were reviewed, staff 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, one (1) 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. LPA toured the facility. All indoor and outdoor passageways were free of obstruction and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the back of facility. LPAs observed laundry detergent, cleaning sprays and Bleach sprays at the outdoor activity area were unlocked and accessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. Cooking knifes are locked and inaccessible to residents. LPAs observed that kitchen roll out drawers are broken and layer of grease on the oven door of the stove. LPAs toured residents rooms. All bedrooms were furnished with required furniture. The bathrooms were observed to be clean, operational. The hot water temperature was tested between 124.5 degrees F which is over the Title 22 regulation.

Continue 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
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 5
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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Document Has Been Signed on 04/22/2025 02:37 PM - It Cannot Be Edited


Created By: Nune Margaryan On 04/22/2025 at 12:09 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: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The hot water temperature was tested between 124.5 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
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The water temperature adjusted at the time of visit. This deficiency is cleared by visit.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed laundry detergent, cleaning sprays and Bleach sprays at the outdoor activity area were unlocked and accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
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Laundry detergent, leaning sprays and Bleach sprays locked immediately. This deficiency is cleared by visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2025 02:37 PM - It Cannot Be Edited


Created By: Nune Margaryan On 04/22/2025 at 12:09 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: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) 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
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Based on observation, the licensee did not comply with the section cited above. LPAs observed that kitchen roll out drawers are broken and layer of grease on the oven door of the stove, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Administrator will ensure to fix the kitchen drawers, clean the oven door and provide proof of correction to CCL by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


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: 04/22/2025
NARRATIVE
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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. 5 fire extinguishers are present in the facility and are fully charged. LPAs observed the facility had the required carbon monoxide detectors and are operable. LPA reviewed 3 residents and 3 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.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
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