198603355-10-28-2022-28-AS-LMOA-CKMQFW-20221028120838

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603355
Report Date: 10/28/2022
Date Signed: 10/28/2022 12:08:51 PM

Document Has Been Signed on 10/28/2022 12:08 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:	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:	DATE:	10/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:08 AM
MET WITH:	Victoria Serna - Care Manager		TIME COMPLETED:	12:25 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) Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met Victoria Serna (Care Manager) and explained the reason for the visit. The facility is licensed to serve six non-ambulatory residents ages 60 and over, of which one may be bedridden, and may retain up to two hospice residents. The facility is operating within the scope of its license. The facility is located in a residential area. A tour of the single-story facility included: 5 resident bedrooms, 3 resident bathrooms, living room, kitchen, dining area, laundry/staff room, front yard and backyard. LPA and Victoria toured the facility and the following was observed: sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in the residents’ bathrooms and measured at 113.5, 112.1, and 111.3 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. The shower has non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in a hallway cabinet. Smoke detectors combined with carbon monoxide were observed in each room and throughout the facility and are properly operating. A fire extinguisher was observed in the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Knives and cleaning chemicals were locked under the kitchen sink. First Aid kit was fully stocked with current manual and it is kept locked in the medication cabinet. The front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. There is a pool surrounded with a locked safety fence. Passageways and exits are free of obstruction Residents medication are centrally stored in a locked cabinet in the laundry/staff room. Residents files are centrally stored in a locked cabinet in the laundry/staff room. Staff files are kept in the licensee’s home which is behind the facility. (CONTINUED TO LIC 809C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLD MEDAL ESTATES	FACILITY NUMBER: 198603355
	VISIT DATE: 10/28/2022

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LPA reviewed medication for 5 of the residents and observed that medications were not given as prescribed for 1 out of the 5 residents. LPA reviewed files for 5 residents and 5 staff, observed no deficiencies. LPA observed administrator certificate for Toni Santos - 6055425740 with an expiration date of 02/19/2024.

Facility is following COVID 19 recommendations regarding screening visitors, staff, and residents. Signs are posted throughout the facility, and hand-washing signs were observed in bathroom. Sufficient hand soap, hand sanitizer, and paper towels were observed. Supply of 30-day Personal Protective Equipment (PPE) was observed in the laundry/staff room.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was one deficiency observed during the visit (refer to LIC 809D). Exit interview held and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 10/28/2022 12:08 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: GOLD MEDAL ESTATES	FACILITY NUMBER: 198603355
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. 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 1 out of 5 residents, which poses an immediate health, safety or personal rights risk to persons in care. R1 still had the medication capsule in the medication bubble pack for Quetiapine Fumarate 25MG Tab #38 (10/21/2022) and Simvastatin 20MG Tablet #31 (10/12/2022).
	POC Due Date: 10/29/2022
	Plan of Correction
1 2 3 4	The administrator shall review the physician's order for all the residents taking medication to ensure that they are being given as prescribed. The administrator shall conduct a medication training for all staff handling medication and submit proof of training log to CCLD by POC due date 11/04/2022.

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

LIC809 (FAS) - (06/04)

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