198603573-7-14-2023-28-AS-ALOZ-CTQRYT-20230714132653

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603573
Report Date: 07/14/2023
Date Signed: 07/14/2023 01:27:07 PM

Document Has Been Signed on 07/14/2023 01:27 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 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: 6	DATE:	07/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:23 AM
MET WITH:	Toni Santos, Administrator		TIME COMPLETED:	01:41 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) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with Administrator Toni Santos and LPA explained the purpose of the visit. The facility has a capacity of 6 residents. It is licensed to serve elderly residents age 60 and above, approved for 6 non-ambulatory residents. Facility is approved for 6 hospice waivers. One bedridden. The facility cares for elderly residents with dementia. Administrator certificate is current and expires on 02/12/2024 LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene, mask and gloves while assisting residents with medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies. Operational Requirements: The facility has plan to accept or retain clients with dementia. The facility has proof on file of enough liability insurance covering injury to residents and guest. Physical Plant & Environment Safety: The facility is in a residential neighborhood and consisted of 5 resident’s bedrooms, 2 bathrooms, living room, kitchen, dining room, activity room, medication room, and activity area in the patio with shade. Facility has fire alarms/carbon monoxide detectors and were tested during visit. Knives are inaccessible to clients. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms sinks. The hot water temperature measured 105.8 degrees F which is between the required range of 105-120 degrees. Staffing: There appears to be sufficient staffing at the facility. Staff employed are all over the age of 18. Personnel Records-Training: Staff files are maintained at the facility. All staff have current CPR/first aid training and evidence of on-going training. (Continued on 809C)

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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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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 SENIOR LIVING GARDENS	FACILITY NUMBER: 198603573
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87615(a)(1)

Prohibited Health Conditions

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure sores (dermal ulcers). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review, the licensee did not comply with the section cited above. facility accepted resident (R1) with stage 3 pressure sore which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2023
	Plan of Correction
1 2 3 4	Administrator will write a plan on how she will address this issue and attend refresher training on prohibited health conditions and send proof to LPA by POC date. DC date for treatment of sores is 6/28/2023

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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 SENIOR LIVING GARDENS	FACILITY NUMBER: 198603573
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation record review, the licensee did not comply with the section cited above. None of the PRN for all residents had labels on bottles which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Administrator will obtain labels for all PRN and send proof to LPA by POC date.

Type B

Section Cited

CCR

87465(d)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation interview, record review, the licensee did not comply with the section cited above. Facility has not PRN authorization letters on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Administrator will obtain PRN authorization letters for all residents and send proof to LPA by POC 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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/14/2023 01:27 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 SENIOR LIVING GARDENS	FACILITY NUMBER: 198603573
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87632(d)(2)

Hospice Care Waiver

(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above. Facility accepted hospice resident and did not notify the department which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/21/2023
	Plan of Correction
1 2 3 4	Administrator will send notification of accepting hospice resident and take refresher training on rules of accepting hospice residents.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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 SENIOR LIVING GARDENS	FACILITY NUMBER: 198603573
	VISIT DATE: 07/14/2023

NARRATIVE

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Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-Admission Current Appraisal are missing on all residents.
Resident Rights-Information: The Complaint poster, Residents personal rights and LET US KNOW are posted by the main entry.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food is properly stored in the refrigerator to avoid cross contamination.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed all 6 residents' medication files and medication is being administered according to doctor’s orders. PRN medications are missing PRN authorization letters and labels or some residents.
Disaster Preparedness: The facility has Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. Facility did not notify department of accepting hospice resident. No Smoking - Oxygen in use signs are posted on the doors of residents using oxygen. Facility accepted resident with stage 3 pressure sore.

Deficiencies cited (See 809D) and technical advisories were also provided. An exit interview was held. A copy of this report, LIC809D, technical advisory notes, and appeal rights were given to Administrator Toni Santos.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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