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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603573
Report Date: 06/16/2024
Date Signed: 06/16/2024 04:21:36 PM


Document Has Been Signed on 06/16/2024 04:21 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 GARDENSFACILITY NUMBER:
198603573
ADMINISTRATOR:SANTOS, TONIFACILITY TYPE:
740
ADDRESS:311 NORTH MOUNTAIN AVETELEPHONE:
(714) 488-7542
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 6DATE:
06/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Care Manager Victoria Serna TIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Caregiver Priscilla Serna and explained the purpose of today’s visit. Care Manager Victora Serna arrived within the hour. This facility is licensed to serve six (6) residents over the age of 59, of which six (6) may be non-ambulatory; (1) may be bedridden. This facility may retain no more than six (6) hospice residents. There is one (1) resident under hospice care. LPA Ramirez observed four (4) staff providing care and supervision during inspection.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be accessible to residents in laundry room. LPA Ramirez observed disinfectants and cleaning solutions located in cabinet above washer and dryer, to be accessible to five (5) out of the six (6) residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected five (5) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be above 120 degrees F. Water temperature in bathroom#1 was measured at 124 degress F, bathroom#2- 122.2 degrees F, and bathroom#3- 123.6 degrees F. LPA Ramirez observe postings encouraging proper handwashing etiquette in restrooms. LPA Ramirez observed grab bars near toilets. LPA Ramirez will issue two (2) Type A deficiencies based on observations.

Food Service: LPA Ramirez observed sufficient supply of nonperishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C).

Planned Activities: LPA Ramirez observed sufficient space to accommodate indoor and outdoor activities. LPA Ramirez observed staff and resident engaging in cognitive abilities game during inspection.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line.

SEE 809-C for continuation.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2024
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 5


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: 06/16/2024
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Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) in place. Last documented emergency drills were conducted on 05/24/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes upon entrance of facility. LPA Ramirez observed emergency food supply in laundry room. Emergency water supply was located in garage.
Residents with Special Needs: No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” was observed. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order.
Health Related Services/Incidental Medical Services: Medications are centrally stored in medications cart and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Six (6) MAR records were compared to medications stored.
Staffing: Administrator Certificate for Tony Santos and expires 02/19/2024. LPA Ramirez observed Administrator’s Certificate for Victoria Santos and expires 08/24/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.
Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed CPR and First Aid for four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel records reviewed. LPA Ramirez did not observe required initial/annual training in personnel files. Care Manager Serna agreed to print completed training and place in personnel files. LPA Ramirez will issue Technical Violation.

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Operational Requirements: The fire clearance is approved for six (6) non-ambulatory residents, of which one (1) may be bedridden. This facility may retain no more than six (6) hospice residents. There is one (1) resident under hospice care.


Resident Records/Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #6 (R-6). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. R5 did not have required annual medical assessment. LPA Ramirez will issue Type B deficiency based on record review.

Three (3) deficiencies were observed during inspection. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/16/2024 04:21 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: 06/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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, all bathroom water temperatures were measured over 120 degrees F, the licensee did not comply with the section cited above in 6 out of 6 residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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**Staff adjusted water heater during visit to clear 24hr immediate correction.** Licensee will retrain staff on above regulation and devolop water log and record water temperature in all grooming areas for the next 3 calendar days. Proof of retraining and water log must be sent to LPA by 6/21/24 via email.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, disinfectants and cleaning supplies were accessible in laundry room cabinet, the licensee did not comply with the section cited above in 3 out of 6 dementia residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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**Staff moved disinfectants and cleaning supplies to inaccessible location during inspection. This clears 24hr correction**
Licensee will retain staff on this regulation and send proof of retraining to LPA by 6/21/24 via email.
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: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 06/16/2024 04:21 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: 06/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R5 did not have annual medical assessment, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Licensee will certify plan to address how updated medical assessment for R5 will be provided and retrain staff on this regulation. Retraining and plan must be emailed to LPA by 6/21/24.
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: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5