198603573-6-21-2022-28-AS-VMAO-CFLQGB-20220621120917

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603573
Report Date: 06/21/2022
Date Signed: 06/21/2022 02:41:28 PM

Document Has Been Signed on 06/21/2022 02:41 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GOLD MEDAL SENIOR LIVING GARDENS		FACILITY NUMBER:	198603573
ADMINISTRATOR:	SANTOS, TONI		FACILITY TYPE:	740
ADDRESS:	311 NORTH MOUNTAIN AVE		TELEPHONE:	(714) 488-7542
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 0	DATE:	06/21/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Toni Santos- Applicant		TIME COMPLETED:	12:30 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's (LPA's), Valeria Maldonado and Kruz Long conducted a visit to the facility for purpose of a pre-licensing evaluation. LPA's met with licensee Toni Santos and explained the purpose of the visit. The facility will be licensed for a Residential Care Facility for the Elderly to serve the Elderly for 60 years and older. The requested capacity is for 6 residents, 1 of which may be ambulatory, 4 may be non-ambulatory, and 1 may be bedridden. LPA Maldonado's and Long's observations during today's visit were as follow: Facility is a (5) bedroom, (3) bathroom, single story home with an attached garage. The home has a large kitchen with the necessary utensils and dishware for residents. Sharps and medication will be stored in kitchen cabinets. Sufficient food was observed in the facility. There is a laundry area where cleaning supplies and first aid kit will be stored separately and locked. The first aid kit had the required items and current first aid manual. There is one restroom (RR#1) in the laundry area with a toilet and wash basin to be used by staff. There is a fire place in the activity room with a metal screen cover, and is inaccessible to residents. There is a shaded patio area in the back yard with a table and chairs. All client bedrooms are spacious and will easily accommodate the client's furnishings. There is a back yard with a shaded seating area and an attached garage for storage. All passageways, walkways, driveway, steps and patios are free from obstructions. The front, back and side areas are free of hazards, such as ladders, gardening tools, motorized equipment. Bedroom #1 is for (1) ambulatory resident. Bedroom #2 and 4 are for non-ambulatory residents, and bedroom# 3 is for a bedridden resident. All bedrooms have the required furniture, linens, and adequate lighting. (Report continued on LIC809-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLD MEDAL SENIOR LIVING GARDENS	FACILITY NUMBER: 198603573
	VISIT DATE: 06/21/2022

NARRATIVE

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All bathrooms have a working toilet, wash basin, and restroom #2 (RR#2) and restroom#3 (RR#3) have a shower. RR#2 will accommodate non-ambulatory clients in a wheelchair.
All bathrooms have the required grab bars and non-skid mats/strips. The water temperature measured at 116.2*F in RR#1, 114.4*F in RR#2, and 112.7*F in RR#3. All within Title 22 guidelines.

Adequate supply of linen, towels, and hygiene supplies were stored in the hallway cabinet. The facility has a working landline telephone system. All required signage is posted & readily available for review in common areas and at the entrance of the facility.

Fire Extinguishera are located in the kitchen and in the hallway near the resident's rooms. A carbon monoxide detector was observed and properly operating in the living room area and all smoke detectors and interconnected and operable.

No bodies of water were observed on the premises.

Administrator Toni Santos has waived the COMP III orientation, as was recently licensed for another facility of the same category and has already completed the orientation.

During the pre-licensing inspection, LPAs did not observe items which do not comply with applicable laws and regulations.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

LIC809 (FAS) - (06/04)

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