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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880617
Report Date: 07/09/2026
Date Signed: 07/09/2026 11:55:08 AM

Document Has Been Signed on 07/09/2026 11:55 AM - 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:GOLDEN EYE RESIDENTIAL CAREFACILITY NUMBER:
331880617
ADMINISTRATOR/
DIRECTOR:		ODOM-JACKSON, BEVERLYFACILITY TYPE:
735
ADDRESS:23066 GOLDEN EYE LNTELEPHONE:
(951) 907-6092
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 2DATE:
07/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Erica Patterson, House LeadTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 07/9/2026, Licensing Program Analyst, (LPA) Ahliah Sharp made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by House Lead, (HL) Erica Patterson who was informed of the purpose of the visit. At the time of the visit, LPA was notified that two (2) clients were present at the facility, but one (1) left shortly after arrival. HL was the sole staff on grounds at the time of the visit and had the necessary clearance and was attached to the facility. The facility has a fire clearance for four (4) ambulatory clients only and serves adults ages 18 through 59.

LPA toured the facility and reviewed both client records. During the tour, LPA observed the facility is made up of a two (2) story home with four (4) client bedrooms, three (3) bathrooms, a living room, dining room, laundry room, backyard and attached garage. All clients’ bedrooms had the required furniture and lighting.

LPA toured the facility's exterior and observed outdoor pathways were free of obstructions. Outdoor shaded seating area is available for the clients in care. LPA observed a hallway cabinet filled with clean towels, blankets, and linen, available for the clients. LPA toured the kitchen and observed the facility has the required 2-day supply of perishable foods and more than a 7-day supply of non-perishable foods. LPA observed knives and sharp instruments secured in a locked hallway closet. Cleaning solutions and disinfectants are secured in a locked laundry room cabinet. Caregiver tested one (1) smoke alarms/carbon monoxide detector and LPA observed it to be operational. LPA also observed two (2) charged fire extinguishers mounted throughout the facility last served on 07/04/2026. Medications are secured in a locked cabinet stored in the hallway closet near the laundry room.

Continued on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Ahliah Sharp
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: GOLDEN EYE RESIDENTIAL CARE
FACILITY NUMBER: 331880617
VISIT DATE: 07/09/2026
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Continued from LIC809...

LPA reviewed the Medication Administration Record along with the physical medications for the one (1) client taking medication. LPA reviewed client files and observed clients had updated Individual Program Plans and signed admission agreements. LPA was initially unable to review personnel records; but HL was able to communicate with Licensee who was able to provide them in full, prior to LPA concluding inspection. LPA communicated with Licensee the importance of having those records accessible and were able to come up with suggestions so that there are no delays with reviewing them moving forward.

The facility conducts monthly preparedness drills, and LPA reviewed the facility's Fire and Earthquake/Disaster drill logs. The most recent were conducted on 7/4/2026 and 6/8/2026 respectively. LPA reviewed the Record of Client's/Resident's Safeguarded Cash Resource and no discrepancies were found; LPA was notified that a new digital (Chime Card) will be implemented.

Exit signs, emergency contact information, client's personal rights, and complaint information are visibly posted on the family living room wall.

Based on today's visit, no deficiencies or citations were issued. An exit interview was conducted, and a copy of this report was provided to HL Erica Patterson.

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Ahliah Sharp
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC809 (FAS) - (06/04)
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