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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004559
Report Date: 09/15/2022
Date Signed: 09/15/2022 03:04:18 PM


Document Has Been Signed on 09/15/2022 03:04 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, 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: 5DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Nargis ElahiTIME COMPLETED:
12:08 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Alvaro Ramirez conducted an unannounced visit for the purpose of conducting a required annual visit. LPAs were 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 9:55 AM, LPAs toured the facility with Administrator Elahi. Facility has five residents in care during today's visit with two on hospice. LPAs 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 single occupancy with Administrator living quarters on the second floor of the facility. LPAs observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet. Facility is not taking/ documenting staff, resident, or visitor temperatures. Facility has covid precaution postings as well as all required department postings. LPAs observed the first aid kit has all required items. Mitigation plan and infection control plan has been submitted. LPAs observed an ample supply of emergency food and water. LPAs toured the outside grounds and observed the shaded outside visitation area. Exit gate is unlocked. LPAs observed the locked medication storage area. At 10:45 AM, LPAs observed unsecured cleaning supplies, knife, and scissors in an unsecured kitchen cupboard. Residents participate in activities such as games, puzzles and exercise. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPAs reviewed select 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 staff and visitors wearing masks inside the facility.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with Administrator and a copy was provided as well as appeal rights
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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 3


Document Has Been Signed on 09/15/2022 03:04 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: GOLDEN HEARTS ELDERLY CARE
FACILITY NUMBER: 306004559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
The following shall be stored inaccessible to residents with dementia:
Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed unsecured cleaning supplies, knife and scissors unsecured in a kitchen cabinet. This poses an immediate health and safety risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Licensee to secure noted items and forward proof to LPA.
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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/15/2022 03:04 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: GOLDEN HEARTS ELDERLY CARE
FACILITY NUMBER: 306004559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and observation, the licensee did not comply with the section cited above. Staff are not taking visitor temps or documenting temps for staff or residents. This poses a potential health and safety risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Licensee to take temperatures and document for all staff, residents and visitors and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3