331800119-7-22-2024-18-AS-SMAZ-D7EUGW-20240722153501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800119
Report Date: 07/22/2024
Date Signed: 07/22/2024 03:35:10 PM

Document Has Been Signed on 07/22/2024 03:35 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GOLD LIVING HOME CARE		FACILITY NUMBER:	331800119
ADMINISTRATOR:	CANDIDATO, FLORINA		FACILITY TYPE:	740
ADDRESS:	10233 BONITA AVENUE		TELEPHONE:	(951) 689-6471
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY:	6	CENSUS: 6	DATE:	07/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Florina Candidato, Administrator		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection at the home. The LPA was allowed entrance into the home and met with Administrator, Florina Candidato. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: Physical Plant: The facility consists of six (6) resident bedrooms, two (2) staff bedrooms, a kitchen, a dining area, a sitting room, a laundry area, a medication room, a garage and storage areas, and a patio with sufficient seating and space for activities. No pools or other bodies of water were observed on the property. According to Administrator, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways were kept free of obstruction and were free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. Bathrooms were clean and in working order. The carbon monoxide and smoke detectors were tested by facility staff and were observed to be in operating condition. The home was kept well clean, free of any odors, and well organized. The home was kept in good repair. Food Service: There is a minimum of two (2) days’ supply of perishable foods and one (1) week supply of non-perishable foods available. Sufficient supplies were available for resident use. The kitchen was observed to be maintained in a clean state. The LPA observed about four (4) cartons of eggs to be stored inappropriately; the cartons were being stored in a kitchen cabinet beside the refrigerator. The LPA observed the label on the carton to indicate, "keep refrigerated". A citation will be issued. Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Personnel records were reviewed; staff responsible for direct care and supervision have current CPR training on file. No First Aid training was observed on file for Staff Two (S2) or Staff Three (S3). A citation will be issued. Resident records were reviewed; medical assessments and admission agreements were observed to be available. The LPA observed Resident Three

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

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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Document Has Been Signed on 07/22/2024 03:35 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLD LIVING HOME CARE	FACILITY NUMBER: 331800119
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 two out of two staff members (S2 and S3) who do not have current first aid training. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	Administrator Candidato stated first aid training will completed for S2 and S3 and proof of the training will be submitted by the POC due date.

Type B

Section Cited

HSC

1569.69(a)(2)

Other Provisions

(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 one out of one staff members (S2) who did not have the required 10 hours of training on file. S2 has been an employee since 2017. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	Administrator stated the required training will be provided to S2 and proof of the training will be submitted by the POC due date.

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: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/22/2024 03:35 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLD LIVING HOME CARE	FACILITY NUMBER: 331800119
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(23)

General Food Service Requirements

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. 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 in that about four (4) cartons of eggs were observed to be stored inappropriately. The cartons were being stored in a kitchen cabinet beside the refrigerator. The LPA observed the label on the carton to indicate, "keep refrigerated". This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/22/2024
	Plan of Correction
1 2 3 4	Facility staff disposed of the eggs during the LPA's visit. POC cleared.

Type B

Section Cited

CCR

87616(b)

Exceptions for Health Conditions

(b) Written requests shall include, but are not limited to, the following: 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 one out of one residents (R3) who did not have proof on file of an approved or submitted exception request for a restricted health condition (RHC). According to Administrator, facility staff assist R3 with their RHC and the resident is not receiving home health or hospice services. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	Administrator stated a letter requesting an exception to retain R3 in care and provide services for their RHC will be submitted by the POC date.

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: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLD LIVING HOME CARE	FACILITY NUMBER: 331800119
	VISIT DATE: 07/22/2024

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(R3) to have a Restricted Health Condition (RHC) during an inspection of the resident's room. There was no proof on file of an approved or submitted exception request for the RHC. According to Administrator, facility staff assist R3 with their RHC and the resident is not receiving home health or hospice services. A citation will be issued. There is a disaster and mass casualty plan in place and emergency drills are being completed. The Administrator's Certificate for Administrator, Florina Candidato, is current and expires on 05/17/2025. The Licensee has an active Liability Insurance, which expires on 10/21/2024. The Licensee (GOLD LIVING HOME CARE,LLC) is currently active with the California Secretary of State. The Licensee currently has an approved Hospice Waiver for six (6) residents and there are currently four (4) residents receiving hospice services at this time.

Medical Related Services: The LPA inspected resident medications and storage areas. Storage areas were observed to be clean and well organized. The required 10 hours of medication training was not observed to be on file for S2. A citation will be issued.

This report was reviewed with Administrator Candidato and a copy was provided, along with the LIC 811s and instructions on appeal rights.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC809 (FAS) - (06/04)

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