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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004771
Report Date: 06/07/2022
Date Signed: 06/07/2022 02:07:21 PM


Document Has Been Signed on 06/07/2022 02:07 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 FLOWER MANOR, LLCFACILITY NUMBER:
306004771
ADMINISTRATOR:FLORICA GHEORGHEFACILITY TYPE:
740
ADDRESS:2411 E. LA PALMA AVE.TELEPHONE:
(714) 215-4283
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 6DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Florica GheorgheTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit for the purpose of conducting a Required - 1 Year evaluation. LPA was greeted and granted entry into the facility by Administrator Florica "Flor" Gheorghe and reason for the visit was explained.

LPA toured the facility with Administrator Gheorghe. There are 5 Residents present, of which 4 are receiving Hospice services. LPA observed signs to be posted at front entrance of facility on COVID-19 precautions, as well as a sign in sheet, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate which expires on 08/03/2023. LPA toured all Residents rooms, all rooms where within regulations. Two of the five residents were alert and stated they were very content with care they receive. Other residents were sleeping. All restrooms observed contained soap, toilet paper and paper towels. Restrooms had proper hand washing signs posted. Facility has operating smoke detectors and audible alarms for each sliding door entrance/exit. Facility has Fire Extinguishers which are fully charged. Facility has ample supply of PPE. Facility has a refrigerator in kitchen and garage with ample food supply. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted, a secured location for resident's medication and files. Facility has 30 days supply of medications for Residents. Residents emergency contact information and Physicians reports are current. Visitor's visit in resident's bedroom.

LPA consulted with Administrator on the importance of following COVID guidelines. Administrator provided LPA with a copy of facility's Infection Control Plan.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator and a copy of report was emailed during today's visit.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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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