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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004559
Report Date:
09/28/2022
Date Signed:
09/28/2022 11:52:25 AM
Document Has Been Signed on
09/28/2022 11:52 AM
- 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
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
GOLDEN HEARTS ELDERLY CARE
FACILITY NUMBER:
306004559
ADMINISTRATOR:
NARGIS ELAHI
FACILITY TYPE:
740
ADDRESS:
27778 BAHAMONDE
TELEPHONE:
(949) 716-0016
CITY:
MISSION VIEJO
STATE:
CA
ZIP CODE:
92692
CAPACITY:
6
CENSUS:
4
DATE:
09/28/2022
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
11:22 AM
MET WITH:
Claudia Navarro and Nargis Elahi
TIME COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Kimberly Lyman conducted an unannounced visit for the purpose of a Plan of Correction (POC) visit based on deficiencies cited on 09/15/2022 . LPA was greeted and granted entry into the facility by Caregiver Claudia Navarro and explained the reason for the visit. Administrator/ Licensee Nargis Elahi arrived during the visit.
*Deficiency cited under Title 22 Regulation 87705(f)(1) pertaining to Care of persons with Dementia has been cleared. Licensee secured noted items. Licensee has complied with the terms of the POC.
*Deficiency cited under Title 22 Regulation 87468.1(a)(2) pertaining to Personal Rights has been cleared. Facility is taking temperatures and documenting. Licensee has complied with the terms of the POC.
Licensee has posted hand washing signs in restrooms as well as the "Let Us No" poster in regulation size.
Licensee has been advised to maintain all items in compliance with Title 22 regulations.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Kimberly Lyman
TELEPHONE:
(714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE:
09/28/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/28/2022
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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