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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603355
Report Date: 10/31/2023
Date Signed: 10/31/2023 10:32:50 AM


Document Has Been Signed on 10/31/2023 10:32 AM - 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:GOLD MEDAL ESTATESFACILITY NUMBER:
198603355
ADMINISTRATOR:SANTOS, TONI CFACILITY TYPE:
740
ADDRESS:4010 GAREY AVETELEPHONE:
(714) 488-7542
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 5DATE:
10/31/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Victoria Serna- House ManagerTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of concluding the required Annual inspection. LPA Maldonado met with Care Manager, Victoria Serna, and explained the purpose for the visit.

Today's visit consisted of the following:
  • Review of (4) resident's medications.
  • Interviews conducted with (2) staff
  • Interviews attempted with (5) residents. LPA was unable to interview some residents due to them sleeping during the visit.


Per California Code of Regulations, Title 22, no deficiencies were observed during today's visit.

An exit interview was conducted with Care Manager, Victoria Serna, and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
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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