306005702-11-4-2021-22-AS-RQUZ-C8FSF6-20211104134948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005702
Report Date: 11/04/2021
Date Signed: 11/04/2021 01:49:52 PM

COMPREHENSIVE INSPECTION

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 HEART CARE HOME		FACILITY NUMBER:	306005702
ADMINISTRATOR:	ENCARNACION, JOEY M.		FACILITY TYPE:	740
ADDRESS:	18976 PERSIMMON STREET		TELEPHONE:	(714) 875-0485
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 4	DATE:	11/04/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:18 PM
MET WITH:	Joey Encarnacion, Licensee/Administrator and Marizonia Llorin, Administrator		TIME COMPLETED:	01:50 PM

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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted, COVID-19 screened and granted entry into the facility by Administrator (AD) Marizonia Llorin and explained the nature of the visit. Licensee/Administrator (L/AD) Joey Encarnacion arrived shortly after.

This facility is licensed to provide services to residents age range 60 and over, 6 Non-Ambulatory Residents; of which (1) one may be bedridden in bedroom #4 only, and has a hospice waiver for six (6) residents. L/AD Joey Encarnacion has an Administrator Certificate with expiration date of 04/20/2022.

On or about 12:33pm, LPA Quiroz along with L/AD Joey Encarnacion toured the inside and outside of facility. There are four (4)residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed two (2) residents in dining-room area finishing up their lunch, (1) one resident in their bedroom reading their bible, and L/AD Encarnacion indicated (1) one resident was out to a medical appointment. Three of four residents present in the facility appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. L/AD Encarnacion indicated facility is taking temperatures daily; and documenting results.

LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food, water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for resident’s enjoyment in backyard area and front porch area.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

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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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 HEART CARE HOME	FACILITY NUMBER: 306005702
	VISIT DATE: 11/04/2021

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Facility has completed the LIC 808 Mitigation plan dated 2/18/2021. The LIC 808 Mitigation Plan was approved by LPA Quiroz during today's visit.

During today's inspection visit, L/AD Joey Encarnacion indicated "All residents and staff at facility are fully vaccinated for COVID-19 and have received their COVID Booster as well." LPA Quiroz reviewed 4 of 4 resident's records during today's visit.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with L/AD Joey Encarnacion, and a copy of this report and LIC 811 were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC809 (FAS) - (06/04)

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