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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005848
Report Date: 10/14/2022
Date Signed: 10/14/2022 03:04:30 PM


Document Has Been Signed on 10/14/2022 03:04 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 AGE SENIOR HOMESFACILITY NUMBER:
306005848
ADMINISTRATOR:MICO, RICO G.FACILITY TYPE:
740
ADDRESS:24982 WILKES PLACETELEPHONE:
(562) 338-4099
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 5DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rico MicoTIME COMPLETED:
03:20 PM
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On 10/14/2022 at 2:00pm, Licensing Program Analyst (LPA) Jessica Cho arrived at Golden Age Senior Homes to conduct an unannounced visit. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on Infection Control. At 2:02pm, LPA Cho was greeted and granted entry by Caregiver Maricar Cadiz and completed the Coronavirus 2019 (COVID-19) screening procedure. LPA met with Licensee/Administrator (Admin) Rico Mico who entered from the garage and stated the purpose of today's visit. As of today, there are no active COVID-19 cases. Facility screens and documents temperatures of visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The Complaint Poster (PUB475) met the size requirement. The Administrator's Certificate expires on 03/25/2024. The facility is licensed for six non-ambulatory residents and has a hospice waiver for six. There are currently two residents living in the facility of which one is in hospice care.

At 2:11pm, LPA Cho conducted a tour with Admin Rico Mico. The two story home consists of five resident bedrooms and four resident bathrooms.There is one private bedroom for the Admin on the second floor. The facility also has a living room, dining room, kitchen, medication closet, and an attached two-car garage with a laundry area. LPA inspected the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperatures and the water temperature measured at 108.3 degrees Fahrenheit in the Bathroom #1, 109.4 degrees Fahrenheit in Bathroom-#2, 108.8 degrees Fahrenheit in Bathroom #3, and 111.2 degrees Fahrenheit in Bathroom #4. LPA Cho inspected the kitchen. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was mounted, fully charged, and purchased on 09/21/2022.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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 AGE SENIOR HOMES
FACILITY NUMBER: 306005848
VISIT DATE: 10/14/2022
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The smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. No bodies of water was present, and there was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and there were no security bars or weapons on the premises. The exit side gate was self-closing and self-latching. LPA observed sufficient supply of emergency food/water and PPEs. The first aid kit met all the required components except a first aid manual.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit. An exit interview was conducted with Licensee/Administrator Rico Mico, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
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