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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005848
Report Date: 04/19/2024
Date Signed: 04/19/2024 05:32:24 PM


Document Has Been Signed on 04/19/2024 05:32 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
ORANGE COUNTY RO, 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: 3DATE:
04/19/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
05:01 PM
MET WITH:Rico Mico, AdministratorTIME COMPLETED:
05:45 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the plan of corrections required after deficiencies were cited on February 9, 2024. LPA was able to clear some of the deficiencies, however two of the deficiencies initially cited were observed not to be resolved and were cited again during the present visit on the attached form LIC809-D.

An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/19/2024 05:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: GOLDEN AGE SENIOR HOMES
FACILITY NUMBER: 306005848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/20/2024
Section Cited
CCR
87705(f)(2)

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Per CCR Section 87705(f)(2) on Care of Persons with Dementia: "The following shall be stored inaccessible to residents with dementia: (...)Over-the-counter medication, nutritional supplements or vitamins, (...) cleaning supplies and disinfectants." This requirement is not met as evidenced by:
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Dangerous item removed during the visit.
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Based on a tour of the physical plant, powdered bleach was observed to have been left accessible to residents on the dining room table. This constitutes an immediate risk to the health, safety and personal rights of individuals in care
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Type B
05/19/2024
Section Cited
CCR87608(a)(5)(B)

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Per CCR Section 87608(a)(5)(B) on Postural Supports: "Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care(...)." This requirement is not met as evidenced by:
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Licensee replaced the full rails with half rails during the visit based on the physician orders on file.
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The bed for one resident not currently receiving hospice care is observed to be equipped with full bed rails. This constitutes a potential risk to the health, safety and personal rights of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2