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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005702
Report Date: 11/18/2024
Date Signed: 11/18/2024 02:46:53 PM

Document Has Been Signed on 11/18/2024 02:46 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GOLDEN HEART CARE HOMEFACILITY NUMBER:
306005702
ADMINISTRATOR/
DIRECTOR:
ENCARNACION, JOEY M.FACILITY TYPE:
740
ADDRESS:18976 PERSIMMON STREETTELEPHONE:
(714) 875-0485
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Joey EncarnacionTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Ruth Martinez and Nancy Guillen conducted an unannounced visit for the purpose of completing an annual required inspection. LPAs arrived at the facility and were greeted and granted entry by Julieta S. Lubugan. The Administrator Joey Encarnacion arrived shortly after and met with LPAs. There are six residents at the facility, four of which are currently in hospice.

LPAs began the tour of the inside and outside of the facility. LPAs observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week non-perishable foods and two days of perishable foods available. There is additional food storage in the pantry and additional food storage in the cabinet/freezer and refrigerator in the garage. The facility is maintained at a comfortable temperature. LPAs inspected that medication is centrally stored in a locked storage cabinet located in dining room. LPAs reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPAs inspected the bathroom and LPAs measured the hot water temperature which measured 118.2 degrees Fahrenheit. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPAs observed that toxic chemicals, cleaning solutions and disinfectants are stored locked in a storage cabinet in the garage. The facility has an available clean supply of linens. LPAs inspected residents’ bedrooms which have sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPAs toured the outside of the facility and observed outdoor passageways are free of obstructions. LPAs observed there are shaded seating areas for residents’ enjoyment.

Continued on LI 809-C
Armando J LuceroTELEPHONE: (714) 703-2866
Nancy GuillenTELEPHONE: (714) 724-3542
DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GOLDEN HEART CARE HOME
FACILITY NUMBER: 306005702
VISIT DATE: 11/18/2024
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LPAs observed a fire extinguisher with service date September 26th, 2024, in the dinning room and garage. Fire drills are conducted quarterly with the last one being done on October 14th, 2024. LPAs began review of records. LPAs reviewed three resident records. All the required documentation was present and current in the residents’ files reviewed. LPAs reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPAs observed records reviewed had a current First Aid certificate.

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

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2866
LICENSING EVALUATOR NAME: Nancy GuillenTELEPHONE: (714) 724-3542
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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