198603355-10-4-2020-28-AS-LMAZ-BU3Q6D-20201004115318

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603355
Report Date: 10/02/2020
Date Signed: 10/04/2020 11:53:28 AM

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:	GOLD MEDAL ESTATES		FACILITY NUMBER:	198603355
ADMINISTRATOR:	SANTOS, TONI C		FACILITY TYPE:	740
ADDRESS:	4010 GAREY AVE		TELEPHONE:	(714) 488-7542
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 0	DATE:	10/02/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Toni Santos, Applicant		TIME COMPLETED:	04:45 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 Analyst (LPA) Linda Almaraz conducted a pre licensing tele-visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this pre licensing visit was conducted telephonically with Applicant Toni Santos. This is the applicants first application for a license. Therefore, a component III was conducted during the visit. There are currently 0 residents living in the facility. The fire clearance has been approved for 5 non-ambulatory and 1 bedridden resident. The applicant has requested to care for 2 hospice residents. The physical plant was toured and the following was observed. This facility is located in a residential neighborhood, single story house, with a small ramp entrance that leads to the front door and it contains (4) bedroom(s), (3) bathrooms, living room, dent, dining area, laundry/pantry room, and kitchen. The fire alarms, smoke alarms and carbon monoxide detectors were tested and operate properly. All appliances in the kitchen were observed to be clean and operational. Sharp objects such as knives are stored in a locked kitchen cabinet. Their fire extinguisher is located in the kitchen hallway. All cleaning solutions and chemicals are locked and stored underneath kitchen sink. The washer and dryer are located next to the kitchen. Medications will be stored in a locked cabinet in the laundry room along with the first aid kit. There is a fireplace located in the front living room which is covered by a screen fence. Dining room has a table and six chairs. Resident rooms were observed to have the required furniture such as bed frames, dressers, chairs and sufficient closet space. Bedrooms also have the required bedding sheets. There are no staff bedrooms. The residents bathrooms have the required grab bars in the shower and near the toilets. The hot water temperature tested at 113.1 degrees F*, which is within the required 105 - 120 degrees. There is sufficient lighting throughout the home. Window and window screens are in good repair. There are no security bars on the windows. There were no obstructions observed on the premises. The home has all the required posters posted. Resident and staff files were not reviewed since there are no residents living in the facility. (Continued on a LIC 809-C)

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020

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: GOLD MEDAL ESTATES	FACILITY NUMBER: 198603355
	VISIT DATE: 10/02/2020

NARRATIVE

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The backyard has a shaded patio area with patio furniture. The home has a pool which has a 5ft, self latching fence around it. Garage is being converted and applicant will reside on premises. Permits for alteration were obtain and copies were provided to LPA.

The following corrections are needed: 5 mattress pads, closet bar for clothing in room #3, and First Aid Manual. Applicant shall submit pictures to LPA as proof of correction via email/fax by 10/5/2020.

A telephonic exit interview was conducted with Applicant and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020

LIC809 (FAS) - (06/04)

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