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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006109
Report Date: 03/19/2024
Date Signed: 03/19/2024 03:14:00 PM


Document Has Been Signed on 03/19/2024 03:14 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 LIFE MANOR IFACILITY NUMBER:
306006109
ADMINISTRATOR:NUNEZ, LORENZIFACILITY TYPE:
740
ADDRESS:2315 E. PURITAN LANETELEPHONE:
(562) 544-9167
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:5CENSUS: 4DATE:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lorenzi Nunez, AdministratorTIME COMPLETED:
03:30 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting a Required Annual Inspection. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit. Administrator Lorenzi Nunez was contacted by phone and arrived later to assist with the visit.

During the inspection, LPA and administrator conducted a tour of the physical plant and observed the following: The facility is a one-story home with four resident bedrooms and two bathrooms. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets and an adequate additional supply is present. The backyard has a shaded sitting area and the route of egress is free of clutter and obstructions. There are currently four residents in care at the facility, three of which are receiving hospice care. Bathrooms faucets and toilets were operational. Water temperature tested at 109F. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Combined smoke and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with up-to-date maintenance. Sharps were observed locked in a drawer in the kitchen. LPA observed cleaning supplies to be stored in a locked cabinet under the kitchen sink and in the laundry area. The medication central storage was also observed to be secure and was reviewed during the facility visit. LPA reviewed four resident files and three staff files. Interviews conducted or attempted with the four residents present along with one staff member on duty.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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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