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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005847
Report Date: 10/15/2020
Date Signed: 10/15/2020 12:32:18 PM

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 LOVING CARE HOMESFACILITY NUMBER:
306005847
ADMINISTRATOR:ALVARADO, MARY JEANFACILITY TYPE:
740
ADDRESS:302 S BRODER ST.TELEPHONE:
(562) 388-5088
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 0DATE:
10/15/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Mary Jean AlvaradoTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Criss Trinidad conducted an announced Pre-Licensing visit via phone FaceTime virtual technology due to the Coronavirus Pandemic and precautionary measures. LPA Trinidad conducted the visit with Administrator Mary Jean Alvarado. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on June 3, 2020 for a capacity of 6 non-ambulatory residents. LPA Trinidad toured the facility and observed the following:

Structure: Facility is a one story, 6 bedroom, 3 bathroom house with an attached garage. There is a back yard secured by two gates both of which are unlocked and self latching. Family Room/ Dining Room: Adequate seating is available in the dining room as well as the family room. LPA observed an operational television in the family room. Bedrooms Clients: All 5 client bedrooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: Both client bathrooms have a working toilet, wash basin, and bathtub/shower. Grab bars were secure and baths had non-slip mats. Linens & Hygiene Supplies: Linen supply is in ample supply for clients in care. Hygiene supplies were observed. Emergency Phone Numbers and Exit Plan: Available for review in the entrance of the dining room. Food Service: Facility has a supply of 2 day perishable and 7 day non-perishable supply of food in the pantry as well as water in the garage. An active menu was observed. Sharps and knives are kept in a locked cabinet in the kitchen. Smoke Detectors: Smoke and carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are mounted and charged throughout the facility. Appliances: Stove, oven, refrigerator, microwave, washer and dryer are clean and operational. All cleaning supplies and soaps are kept in a locked cabinet. Water Temperature: Tested and recorded to be 118 degrees F. Medications, First-Aid Kit & Book: First aid kit was in the kitchen and contained all required items. Medication is stored and locked in a cabinet in the kitchen. CONTINUED ON LIC809C...

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Criss TrinidadTELEPHONE: (714) 321-8277
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020
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 LOVING CARE HOMES
FACILITY NUMBER: 306005847
VISIT DATE: 10/15/2020
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Clients & Staff File: Records are locked in a filing cabinet in the garage. Reading Material, Games, and Equipment: The facility had books and television. Backyard: LPA observed a locked shed that was being used to store household items. The backyard and side yards were free from obstructions and there were no bodies of water observed. Fire clearance: Approved for 6 non-ambulatory residents on September 3, 2020 by the Orange County Fire Authority.

Component III Orientation points were discussed and was waived due to applicant manages multiple facilities and is familiar with components of orientation.

The Pre-Licensing inspection is now complete and this facility is recommended for licensure and Centralized


Application Bureau will be notified.

An exit interview was conducted and a copy of this report was provided to applicant via email. Report to be signed by applicant and returned via email within 24 hours.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Criss TrinidadTELEPHONE: (714) 321-8277
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020
LIC809 (FAS) - (06/04)
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