306005702-10-20-2022-22-AS-RQUZ-CKDNKT-20221020103228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005702
Report Date: 10/20/2022
Date Signed: 10/20/2022 10:32:33 AM

Document Has Been Signed on 10/20/2022 10:32 AM - 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 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: 6	DATE:	10/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Marizonia Llorin, Administrator and Joey Encarnacion, Licensee/Administrator.		TIME COMPLETED:	10:32 AM

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On today’s date, Licensing Program Analysts (LPAs) LPA Rosie Quiroz and LPA Alvaro Ramirez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPAs were greeted, COVID-19 screened and granted entry into the facility by Caregiver 1. Administrator (AD) Marizonia Llorin and (L/AD) Joey Encarnacion arrived shortly after. LPAs explained the nature of the visit.

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. Facility is currently providing services to (6) six residents receiving hospice services.

L/AD Joey Encarnacion has an Administrator Certificate with expiration date of 04/14/2024.

On or about 9:37am, LPAs along with L/AD Joey Encarnacion toured the inside and outside of facility. There are six (6)residents in care and there are no active COVID-19 cases. During today's inspection visit, LPAs observed four (4) residents in dining-room area eating breakfast, (1) one resident in their bedroom watching television and (1) resident in the living room watching television. Six of six residents present in the facility appeared to be clean and well taken care of. LPAs 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. LPAs inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. Water temperatures in 2 of 2 bathrooms were recorded to be between 108.6-109.0 degrees Fahrenheit. Facility indoor temperature was recorded to be 78 degrees Fahrenheit.

LPAs observed a check in station in the main entry of the facility. L/AD Encarnacion indicated facility is taking temperatures daily twice per day and documenting results.

LPAs observed the emergency disaster and evacuation plan. Facility has back-up emergency food, water supply as well as PPE supplies. LPAs 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. CONTINUED ON NEXT PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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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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: 10/20/2022

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CONTINUED...

Facility has completed the LIC 808 Mitigation plan dated 2/18/2021. The LIC 808 Mitigation Plan was approved by LPA Quiroz on 11/4/2021.

During today's inspection visit, L/AD Joey Encarnacion indicated "All residents and staff at facility are fully vaccinated for COVID-19, Boostered and awaiting scheduling for third booster." LPAs reviewed 6 of 6 resident's records during today's visit.

During today's visit LPAs provided consultation on Infection Control, Title 22 and The Great California Shakeout earthquake preparedness drill taking place today at 10:20am.

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-Confidential Names 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: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC809 (FAS) - (06/04)

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