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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603355
Report Date: 09/13/2024
Date Signed: 09/13/2024 04:43:56 PM


Document Has Been Signed on 09/13/2024 04:43 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
MONTEREY PARK ASC, 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:
09/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:DSP Priscilla SernaTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA was met by Caregiver Priscilla Santos and explained the purpose of the visit. House manager Victoria Santos and Licensee Eduardo Medal arrived shortly. Facility is licensed to serve residents over 60 years old six (6) can be non-ambulatory, of which one (1) may be bedridden in room #4. Approved hospice waiver for six (6). During today’s visit it was observed facility had one (1) staff S5 member who has yet to be fingerprinted civil penalties assessed.

The facility is a single-story building located in a residential area five (5) resident bedrooms, three (3) resident bathrooms, living room, kitchen, dining area, laundry/medication room, front yard backyard with gated pool, pool house and ADU. LPA obtained city permits for ADU however it was observed during tour of facility that ADU was occupied by someone not associated with facility with no fingerprint clearance civil penalties assessed.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in a hallway closet. Auditory devices were observed at entrances/exits and operating properly. Smoke detectors/carbon monoxide were observed in each room and throughout the facility and are properly operating. The facility has one (1) fully charged fire extinguisher which is kept in the kitchen. Cleaning supplies and toxic substances were observed to be inaccessible to clients in laundry room. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Sharps are locked and placed in cabinet in kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. LPA observed scissors in drawer unlocked in bathroom #1 and no grip bars in bathroom #1-2 deficiency cited. There is a pool surrounded with a locked safety fence. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
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 4


Document Has Been Signed on 09/13/2024 04:43 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
MONTEREY PARK ASC, 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: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(4)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.

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 two (2) out of three(3) bathrooms did not have grip bars in shower which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2024
Plan of Correction
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Facility will install grab bars in showers and send a picture as proof to LPA.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 LPA observed scissors unlocked in bathroom #1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2024
Plan of Correction
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Lead Caregiver removed scissors during time of visit and House Mgr will conduct training with all staff and send training to LPA.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 09/13/2024 04:43 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
MONTEREY PARK ASC, 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: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

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 one (1 ) staff and one (1) resident did not have fingerprint clearence which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2024
Plan of Correction
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*24HR CORRECTION met due to S5 removing herself from the facility until criminal clearance is submitted.* Licensee will retrain staff on this regulation and send proof of re-training by 9/14/2024 via email. Resident in ADU left house and will not return unless he is a staff affiliated with home.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOLD MEDAL ESTATES
FACILITY NUMBER: 198603355
VISIT DATE: 09/13/2024
NARRATIVE
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Four (4) Staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Four (4) Client files were reviewed and included physicians report, TB clearance. Fire/earthquake drill was last conducted August 4th, 2024. Infectious control plan was reviewed. The medications are centrally stored and locked in laundry room. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for Four (4) clients, and they are being administered as prescribed by the physician.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4