336402995-9-8-2021-18-AS-MBRN-C6NRTY-20210908131905

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336402995
Report Date: 09/08/2021
Date Signed: 09/08/2021 01:19:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GOLDEN CARE SENIOR LIVING ON WILSON		FACILITY NUMBER:	336402995
ADMINISTRATOR:	PENDING		FACILITY TYPE:	740
ADDRESS:	5466 W. WILSON		TELEPHONE:	(951) 845-7734
CITY:	BANNING	STATE: CA	ZIP CODE:	92220
CAPACITY:	30	CENSUS: 10	DATE:	09/08/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Juanita Veloso		TIME COMPLETED:	01:20 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 Analysts (LPA) Melody Brown made an unannounced visit to facility to conduct an annual inspection, with emphasis on infection control. LPA Brown was greeted and granted entrance by caregiver Nymia Pontillas and explained the purpose of today's visit. Administrator Juanita Veloso was contacted and arrived at the facility. Administrator Veloso accompanied LPA Brown on a tour of the inside and outside of the facility. On today’s visit LPA Brown learned that the facility was recently sold. Licensee John Cassar was contacted, and he confirmed that he sold the facility on September 9, 2021 but added that he has a Management Agreement to continue overseeing the daily operations of the home. The Management Agreement went into effect on September 1, 2021. Also, Licensee Cassar said that he is responsible for all the residents in the facility. LPA Brown informed Licensee Cassar that he sold the facility and no longer has control of the property, thus LPA Brown informed the Licensee Cassar that a Rental/Lease Agreement is needed to continue to have control of property. Licensee Cassar confirmed that he understood and would be obtaining a Lease/Rental agreement effective September 1, 2021. Also, LPA Brown contacted Christine Juarez, the new owner of the facility and informed her that she needs to submit her license application the soonest possible. LPA Brown requested that documents showing control of property be submitted by September 10, 2021. During today’s visit, LPA Brown conducted the annual inspection. LPA Brown made observations pertaining to the facility’s current infection control measures. LPA Brown observed a screening area, proper signage throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a 30+ day supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN CARE SENIOR LIVING ON WILSON	FACILITY NUMBER: 336402995
	VISIT DATE: 09/08/2021

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
26
27
28
29
30
31
32

The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and clients for COVID-19, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client’s physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, no deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to Administrator Veloso.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2