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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005847
Report Date: 10/27/2021
Date Signed: 10/27/2021 03:30:23 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:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Liza DelaCruz, LicenseeTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA arrived at facility, no answer at the door. LPA called facility number and was informed by Licensee that there are no residents in the facility currently. Licensee arrived shortly after and met with LPA. LPA explained the nature of the visit.

LPA Martinez accompanied by Licensee toured the physical plant of the facility. There are no residents in care at the moment. Licensee was approved in October 2020 and never received any residents. LPA observed a check in station in the main entry of the facility. LPA observed required department postings, covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All restrooms observed to have ample supply of soap/sanitizer and appeared to be clean. LPA inspected residents’ bedrooms and appeared to be clean and sanitary. All bedrooms observed to have all required components. LPA observed the emergency disaster and evacuation plan posted. Facility has the back-up emergency food and water supply as well as PPE supplies in the attached garage. Facility was observed to be ready in the case facility receives a resident. LPA reminded Licensee to notify LPA when facility admits any residents to the facility. The facility has completed the LIC808 Mitigation Plan, LPA reviewed and approved the plan on today’s visit. LPA emailed the signed and approved plan to the Licensee for their records.

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 the Licensee and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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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