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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005847
Report Date: 09/22/2022
Date Signed: 09/22/2022 02:30:16 PM


Document Has Been Signed on 09/22/2022 02:30 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
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: 5DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Licensee/Administrator - Liza DelacruzTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 5 staff were on duty, including facility administrator (AD) Liza Delacruz. As of 9/22/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted in the kitchen and at the entrance of the facility. The PUB475 "See Something, Say Something" poster was also observed at the entrance of the facility. LPA observed the Administrator's Certificate for Liza Delacruz, which expires on 11/18/23 and Priscilla Celis which expires on 7/7/23.

LPA De Perio toured the interior and exterior portions of the facility with AD Delacruz. The facility is a single level structure and is licensed for residents 60 years of age and over, 6 non-ambulatory, 0 bedridden and 6 hospice. For this visit, there are a total of 5 residents in care, of which 1 is on hospice, and 0 bedridden. There are a total of 7 bedrooms, of which 4 are private rooms for residents, 1 shared room for resident and 2 are for staff. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 3 restrooms of which 1 is for staff use and 2 are for residents. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 108.1 degrees Fahrenheit and hand washing signs were also posted in each restroom.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were located under the kitchen sink, locked and inaccessible to residents in care. Fire extinguisher was charged and located in the kitchen.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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 LOVING CARE HOMES
FACILITY NUMBER: 306005847
VISIT DATE: 09/22/2022
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LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the kitchen. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the garage. Medications were locked in a cabinet located in the kitchen. Toxins were also observed to be inaccessible to residents in care and locked in the garage.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which both are self-closing and self-latching. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Delacruz. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA De Perio discussed with AD Delacruz to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

LPA De Perio discussed the California Code of Regulations Section 87466 Observation of the Resident and Section 87211 Reporting Requirements with AD Delacruz

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio advised AD Delacruz to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Delacruz and a copy of this report and copies of the regulations discussed were provided to the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC809 (FAS) - (06/04)
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