336412249-12-5-2023-18-AS-CNWE-CY8TZ7-20231205140952

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336412249
Report Date: 12/05/2023
Date Signed: 12/05/2023 02:09:59 PM

Document Has Been Signed on 12/05/2023 02:09 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:	GOLDEN OAK RESIDENTIAL CARE		FACILITY NUMBER:	336412249
ADMINISTRATOR:	ABIGAIL MEJARES		FACILITY TYPE:	740
ADDRESS:	36190 CHITTAM WOOD PLACE		TELEPHONE:	(951) 461-9971
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY:	6	CENSUS: 6	DATE:	12/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Cristina Uy, Caregiver		TIME COMPLETED:	02:20 PM

NARRATIVE

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On 12/5/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Caregiver, Cristina Uy who was informed of the purpose of the visit. At the time of visit there was 2 staff and 5 residents present. LPA was informed that the other resident went out with family. LPA toured the facility inside and out with Cristina Uy.

Tour included:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the census. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen cabinet under the sink, available only to authorized individuals. Trash cans has tight-fitting lid. Dishwasher is used to clean and sanitize dishes. Fridge, freezer, and all need appliances were present and shown to be in working condition and clean.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 72 degrees Fahrenheit.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medication: Medications were labeled and stored in separate bins inside of a locked kitchen cabinet and are distributed according to physician orders. The first aid kit was complete.

Continue on LIC809-C

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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 12/05/2023 02:09 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: GOLDEN OAK RESIDENTIAL CARE	FACILITY NUMBER: 336412249
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(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 by having the hot water temperature at 134 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	LPA observed Caregiver, Neil Garcia adjust the water temperature. Cristina Uy stated a picture of the adjusted hot water temperature will be provided to LPA.

Section Cited


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

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: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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: GOLDEN OAK RESIDENTIAL CARE	FACILITY NUMBER: 336412249
	VISIT DATE: 12/05/2023

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Continued from LIC809.

Bathroom: LPA toured hall bathroom and observed bathroom to be clean and equipped with grab bar and non-skid mat. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 135 degrees Fahrenheit which is above regulatory standard (citation will be issued).

Bedroom: LPA toured four #4 out of #4 resident bedrooms and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs, and lighting. Night lights were maintained throughout the facility. Resident #4 bedroom has a private bathroom. LPA observed bathroom to be clean and hot water was measured at 135 degrees Fahrenheit.

Garage: LPA tour the garage and observed garage to be clean and not cluttered.

Laundry: Washing machine and dryer are all in good repair and sufficient for census. Cleaning supplies are stored away in the laundry room, inaccessible to clients.

Backyard: LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gate remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents. Fridge and freezer are large enough to accommodate required perishable foods.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Two #2 staff and three #3 residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expires on 12/18/2023.

Interview: two #2 staff and five #5 residents were interviewed.

Therefore, based on the observations made during today’s visit, one #1 deficiency will be cited per Title 22, Division 6 of the California Code of Regulations. See LIC809-D. An exit interview was conducted, and this reported was provided along with appeal rights to Cristina Uy.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

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