Community Care Licensing

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024

Document Has Been Signed on 03/26/2024 01:14 PM - It Cannot Be Edited

FACILITY NAME: GOLDEN LIVING HOME CARE	FACILITY NUMBER: 312700989
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above with water temperature being measured at 130 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2024
	Plan of Correction
1 2 3 4	Administrator agrees to turn down the water temperature in the facility. Administrator to send LPA a picture of thermometer measuring water temperature between 105-120 degrees by 3/27/24.

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above and LPA observed medications unlocked in the common area which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2024
	Plan of Correction
1 2 3 4	Administrator removed medications immediately and locked medications up in the medication room. Administrator agrees to submit into LPA a plan of how they will ensure all resident medications are locked. Plan to be sent into CCL by 3/27/24.

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024

Document Has Been Signed on 03/26/2024 01:14 PM - It Cannot Be Edited

FACILITY NAME: GOLDEN LIVING HOME CARE	FACILITY NUMBER: 312700989
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 3 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator to obtain a health screening and TB test for caregivers. Health screening and TB tests to be sent into CCL by 4/19/24.

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024

Document Has Been Signed on 03/26/2024 01:14 PM - It Cannot Be Edited

FACILITY NAME: GOLDEN LIVING HOME CARE	FACILITY NUMBER: 312700989
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

Type B

Section Cited

CCR

87208(a)(12)

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above and did not have an infection control plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator agrees to complete an infection control plan. Completed plan to be sent into LPA by 4/19/24.

Type B

Section Cited

HSC

1569.69(a)(2)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator agrees to complete the 10 hours of initial training with her caregivers. Completed training to be sent into CCL by 4/19/24.

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024

Document Has Been Signed on 03/26/2024 01:14 PM - It Cannot Be Edited

FACILITY NAME: GOLDEN LIVING HOME CARE	FACILITY NUMBER: 312700989
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

Type B

Section Cited

CCR

87458(a)

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 4 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator to obtain a physcian report for R1. Administrator to send into LPA a completed and signed physcian report by 4/19/24.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024

Document Has Been Signed on 03/26/2024 01:14 PM - It Cannot Be Edited

FACILITY NAME: GOLDEN LIVING HOME CARE	FACILITY NUMBER: 312700989
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

Type B

Section Cited

CCR

87467(a)(3)

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 4 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator agrees to update resident needs and service plans annually. Adminsitrator to send into CCL a copy of the updated needs and service plan for R2 and R3.

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024

Document Has Been Signed on 03/26/2024 01:14 PM - It Cannot Be Edited

FACILITY NAME: GOLDEN LIVING HOME CARE	FACILITY NUMBER: 312700989
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

Type B

Section Cited

CCR

87507(c)

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 4 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator agrees to have licensee sign R2's admission agreement. Signed admission agreement to be sent into CCL by 4/19/24.

Type B

Section Cited

CCR

87507(d)

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 4 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator agrees to complete an admission agreement for R1 that is signed by all parties. Administrator to send into LPA a copy of completed admission agreement by 4/19/24.

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024

Document Has Been Signed on 03/26/2024 01:14 PM - It Cannot Be Edited

FACILITY NAME: GOLDEN LIVING HOME CARE	FACILITY NUMBER: 312700989
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

Type B

Section Cited

HSC

1569.695(a)(2)

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having a completed 610E form which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator agrees to complete all 9 pages of 610E. Completed 610E to be sent into CCL by 4/19/24.

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in not completing fire drills quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Adminsitrator agrees to complete fire drills quarterly. Administrator to complete1 fire drill by 4/19/24 and send LPA the documentation.

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024