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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005683
Report Date: 04/21/2022
Date Signed: 04/21/2022 01:39:39 PM


Document Has Been Signed on 04/21/2022 01:39 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 LIVING, LLCFACILITY NUMBER:
306005683
ADMINISTRATOR:ORTIZ-LUIS, VIVIANFACILITY TYPE:
740
ADDRESS:8552 CODY AVETELEPHONE:
(657) 227-8331
CITY:WESTMINISTERSTATE: CAZIP CODE:
92683
CAPACITY:6CENSUS: 5DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Vivian Ortiz-LuisTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Jessica Cho and Kathrina Chin made an unannounced required annual inspection (mitigation) in this facility. LPAs were greeted and granted entry by Consolacio Vallesteros, Caregiver and Marthe Akama Nkoa, Caregiver. Vivian Ortiz-Luis, Administrator joined shortly at 12:25 PM and stated the purpose of this visit.

The facility is a single level structure and licensed for six non-ambulatory residents of which one may be bedridden and has a hospice waiver for six residents. There are one resident in hospice. LPAs were granted entry after completing the Coronavirus 2019 COVID-19 screening procedure. For this visit, there are five residents in care and two staff members on duty. LPAs toured the interior and exterior portions of the facility. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with handrails and nonskid - floor mats. Hot water was measured at 117.1 degrees Fahrenheit in Bathroom #1, 117.5 degrees Fahrenheit in Bathroom #2, and 117.1 degrees Fahrenheit in Bathroom #3. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to residents in care. The fire extinguisher was mounted and charged. For the exterior portion, facility had outdoor furnitures under a patio lattice. The grounds were free of tripping hazards. Side exit door was self-latching and self-closing. LPAs reviewed the COVID-19 Mitigation Plan.

For this visit, there are no deficiencies cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit and LPA Cho will follow-up with the corrections. An exit interview was conducted with Vivian Ortiz-Luis, Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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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