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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004559
Report Date: 09/01/2021
Date Signed: 09/01/2021 03:20:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GOLDEN HEARTS ELDERLY CAREFACILITY NUMBER:
306004559
ADMINISTRATOR:NARGIS ELAHIFACILITY TYPE:
740
ADDRESS:27778 BAHAMONDETELEPHONE:
(949) 716-0016
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:6CENSUS: 6DATE:
09/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Nargis ElahiTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Administrator Nargis Elahi and explained the reason for the visit. Administrator Nargis Elahi has an administrator certificate expiring on 11/11/2022.

At 1:35 PM, LPA toured the facility with Administrator Elahi. Facility has 6 residents in care during today's visit with two on hospice. LPA observed residents relaxing in the facility. All residents appeared well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Rooms are double and single occupancy with Administrator living quarters on the second floor of the facility. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet. Facility has covid precaution postings as well as all required department postings. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food and water. LPA toured the outside grounds and observed the shaded outside visitation area. Exit gate is unlocked. LPA observed the locked medication storage area. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed six resident files during the visit and all files have updated emergency information. All residents and staff are vaccinated for Covid-19.

LPA consulted with Administrator regarding the importance of documenting visitor temperatures and status of symptoms upon entry into the facility as well as the importance of inside visitors wearing masks.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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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