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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603355
Report Date: 10/23/2023
Date Signed: 10/31/2023 09:07:28 AM


Document Has Been Signed on 10/31/2023 09:07 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: 4DATE:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Victoria Serna- House ManagerTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Care Manger, Victoria Serna, and explained the purpose for the visit.

During today's visit, LPA Maldonado conducted a tour of the physical plant with Licensees, observed the facility food supplies, reviewed (4) resident files, and attempted to review (4) staff files. The facility is a single-story home, operating as an Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (6) non-ambulatory residents, of which (1) may be bedridden, in room#4, only. There is a hospice waiver approved for (2). Currently, there is (1) resident on hospice.

All resident bedrooms were inspected and had the required furniture, storage space, and lighting. Bathrooms were equipped with a toilet, wash basin, and showers. They were observed to have the required grab bars and non-skid mats. The water was tested and measured at 114*F in bathroom (BR)# 1, the water in BR#2 had a trickle of water coming out of the faucet when opened- in disrepair, and water in BR#3 did not have hot water. LPA and house manager left the hot water running for about 10 minutes, and the water did not turn hot. The food supplies was observed and had the required 2-day perishables and 7-day non-perishables. Fire extinguishers were observed throughout the premises, with current inspections and were fully charged. Walkways and ramps were observed to be free of debris and obstructions/hazards. Sharps were observed stored in the kitchen, inaccessible to residents in care. Toxins and cleaning supplies were observed stored in the laundry room and underneath the kitchen sink, locked and inaccessible to residents in care. Centrally stored medications were also observed stored inaccessible to residents. Auditory devices were observed at entrances/exits and operating properly. Sufficient linens, towels, and personal hygiene supplies were available. (Report Continued on LIC809-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
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


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: 10/23/2023
NARRATIVE
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The facility has an approved mitigation plan on file and a current infection control plan submitted to the department. Smoke/carbon monoxide detectors were observed in each room. The last fire drill was conducted on 8/30/23. Resident files were reviewed for required documentation, and observed to be complete. (3) of (4) staff files were reviewed and had the required documents. (1) staff file was unavailable to review at the facility during the time of the visit. At 2:05PM, LPA observed Staff#1's (S1) bed inside the kitchen area, separated by curtains. Per S1, S1 is a live-in staff and that is their room.

Due to time constraints, LPA was unable to conclude the required Annual Inspection. The following domains are pending completion: Incidental Medical and Dental. Staff and Resident interviews are also pending to be conducted.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed and will be cited on the LIC809-D.

An exit interview conducted with Care Manager and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/31/2023 09:07 AM - 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
CCLD Regional Office, 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: 10/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)
87307 Personal Accommodations and Services
(a)Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in a staff bedroom located inside the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Licensee will remove staff room inside the kitchen and send LPA a picture of the kitchen cleared, via email, by 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.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 10/31/2023 09:07 AM - 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
CCLD Regional Office, 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: 10/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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 and interview, the licensee did not comply with the section cited above in the sink faucet in bathroom# 2 is not operational, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee will send LPA, via email, a copy of the work receipt indicating the work completed and faucet operational.
Type B
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 in bathroom# 3 sink faucet not delivering any hot water, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee will have sink faucet repaired and send LPA a work recipt of it fixed. Will also include a water log for (5) days and submit to LPA, via email, by POC due date.
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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 10/31/2023 09:07 AM - 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
CCLD Regional Office, 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: 10/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in the facility Administrator not maintaining a file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee will compile a complete file for Administrator and send LPA a statement with a checklist of all required documents, indicating that the file is complete to best of their knowledge and will maintain all employee files, including licensee and administrator at the facility at all times. To send to LPA via email by 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.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5