198603355-10-25-2021-28-AS-AGOZ-C86834-20211025220856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603355
Report Date: 10/25/2021
Date Signed: 10/25/2021 10:08:57 PM

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: 4	DATE:	10/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Toni Santos		TIME COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Annual Required / Infection Control Visit to the above facility. LPA was met by Administrator Toni Santos and the purpose of today’s visit was explained.

There are currently (4) residents in the facility. 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 (5) bedroom(s), (3) bathrooms, living room, dining area, laundry/pantry room, and kitchen. Physical plant inside and outside is in good repair.

LPA and Administrator Toni Santos toured the entire facility inside and out. Documents are posted as mandated. Resident bedrooms contain the mandated furniture. The bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility. The home has a pool which has a 5ft, self latching fence around it which was secured during the visit. Medications are locked cabinet in the laundry room along with the first aid kit and are inaccessible. Food supply was adequate for 2-day perishable and 7-day non-perishable. Hot water temperature is 110 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to clients, Exit, walkways and/or passageways, are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged and temperature checked, sanitizer/soap located throughout the facility and additional sanitation supplies are stored in the facility. LPA observed staff and residents wearing masks and keeping 6 ft distance from one another. Resident vacant room will be converted to isolation room (if needed) and required postings placed throughout the facility. The residents temperature's are checked and logged once a day as well as facility staff. PPE's are enough for 30 days.

According to the California Code of Regulations, LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator Toni Santos and a copy of report provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

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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