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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881309
Report Date: 06/19/2024
Date Signed: 06/19/2024 03:52:01 PM

Document Has Been Signed on 06/19/2024 03:52 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:GOLDEN HORIZON SENIOR CAREFACILITY NUMBER:
361881309
ADMINISTRATOR/
DIRECTOR:		HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:1524 S EUCLID AVETELEPHONE:
(786) 564-3771
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 22CENSUS: 21DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Licensee/Administrator Ebraheem HamedTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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On 06/19/2024 at 09:20 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with Licensee/Administrator Ebraheem Hamed and was granted entry to the facility. At the time of the visit there was two (2) staff present, and sixteen (16) residents present. LPA Brown explained the purpose of the visit to Licensee/Administrator Ebraheem Hamed.

The facility is eleven (11) bedroom, seven (7) bathroom home with a kitchen/dining area, living room, activity room and laundry area. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of twenty-two (22) ambulatory residents. The current census is twenty-one (21) residents. LPA Brown was accompanied by Licensee/Administrator Ebraheem Hamed to conduct a general overall inspection, which included, but was not limited to the following:


Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. LPA Brown observed sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms.

Moreover, during the tour of the facility, LPA Brown observed the knives drawer not locked and accessible to residents in care. Deficiency will be issued. In addition, LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 113 degrees Fahrenheit. LPA Brown observed one (1) window screen in disrepair. Technical Violation issued. LPA Brown observed movable waste bin in the kitchen does not have a cover. Deficiency will be issued. ***Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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 33
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
, CA 92507
FACILITY NAME: GOLDEN HORIZON SENIOR CARE
FACILITY NUMBER: 361881309
VISIT DATE: 06/19/2024
NARRATIVE
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The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster, Labor Laws and the Emergency Disaster plan were posted in a common area.

Also, LPA Brown observed that the facility does not have signal system. Deficiency will be issued. All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:


There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the Office room.

Food Service: Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator present in the facility. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA reviewed eight (8) resident files for pre-placement appraisals, admission agreements, updated physician reports, and needs and services plans. LPA Brown observed five (5) of eight (8) files reviewed for physician’s reports do not have Physician signature date. Deficiency will be issued. LPA reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown found that Staff #2 (S2) and Staff #4 (S4) do not have Health Screening Report and Tuberculosis Test Result in their facility file as there's no physician signature in their Health Screening Reports. Deficiency will be issued. Furthermore, LPA Brown observed Staff #2 (S2) and Staff #4 without current cardiopulmonary resuscitation (CPR) training and first aid training Deficiency will be issued. Lastly, LPA Brown did not observe required trainings provided to the staffs at the facility. Deficiency will be issued.

Also, three (3) residents medications were audited and LPA Brown observed that there's one medication not listed in Resident #2 (R2) Medication Administration Record (MAR) at the facility and LPA Brown observed that the facility's dispensing or giving R2's medications. Deficiency will be issued. To add to that, LPA Brown observed that Resident #9 (R9) medication was dispensed/given but Staff #2 (S2) did not sign/update R9's MAR. Deficiency will be issued.

An exit interview was conducted where this report, (LIC809), LIC809D, LIC9102 and Appeal Rights were discussed and provided to Licensee/Administrator Ebraheem Hamed.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 33
Document Has Been Signed on 06/19/2024 03:52 PM - It Cannot Be Edited


Created By: Melody Brown On 06/19/2024 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GOLDEN HORIZON SENIOR CARE
FACILITY NUMBER: 361881309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not locking the multiple knives in the kitchen drawer, and making it accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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Licensee immediately locked the multiple knives in the kitchen drawer during the visit. Plan of Correction (POC) cleared.
Licensee stated to train all staff on CCR 87309(a)(1) and submit proof of training log to LPA Brown on POC due date.
Type A
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
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2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above
by not ensuring that Staff #2 (S2) and Staff #4 (S4) have current cardiopulmonary resuscitation (CPR) training and first aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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2
3
4
Licensee submitted S2 current CPR/First Aid Training which was completed during the visit.
Licensee stated to submit proof of S4 CPR/First Aid Training to LPA Brown on 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 33
Document Has Been Signed on 06/19/2024 03:52 PM - It Cannot Be Edited


Created By: Melody Brown On 06/19/2024 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GOLDEN HORIZON SENIOR CARE
FACILITY NUMBER: 361881309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not having a Health Screening Report completed for Staff #2 (S2) and Staff #4 (S4) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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Licensee stated to submit S2 and S4 completed Health Screening Report and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not having Staff #2 (S2) and Staff #4 (S4) complete a Tuberculosis (TB) test signed by a physician and no TB Test result maintained in S2 and S4 facility file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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2
3
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LIcensee stated to submit S2 and S4 completed TB Test with results and submit proof to LPA Brown on 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
Page: 4 of 33
Document Has Been Signed on 06/19/2024 03:52 PM - It Cannot Be Edited


Created By: Melody Brown On 06/19/2024 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GOLDEN HORIZON SENIOR CARE
FACILITY NUMBER: 361881309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not providing the required on the job training to Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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LIcensee stated to submit Signed Statement of Understanding on CCR 87411(d) to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
Page: 5 of 33
Document Has Been Signed on 06/19/2024 03:52 PM - It Cannot Be Edited


Created By: Melody Brown On 06/19/2024 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GOLDEN HORIZON SENIOR CARE
FACILITY NUMBER: 361881309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not providing the required 40 hours of training to staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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2
3
4
Licensee stated to provide the required 40 hours training to all staff and submit proof to LPA Brown on Plan of Correction (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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
Page: 6 of 33
Document Has Been Signed on 06/19/2024 03:52 PM - It Cannot Be Edited


Created By: Melody Brown On 06/19/2024 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GOLDEN HORIZON SENIOR CARE
FACILITY NUMBER: 361881309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.696(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not providing the required four hours of training to staffs on the care, supervision, and special needs of those residents, prior to providing direct care to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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2
3
4
Licensee stated to provide the required four hours of training to staffs on the care, supervision, and special needs of those residents and submit proof to LPA Brown on POC due date.
Type A
Section Cited
HSC
1569.696(a)(2)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (2) Four hours of training thereafter of in-service training per year on the subject of serving those residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not providing the required four hours of training per year to staffs which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
1
2
3
4
Licensee stated to submit Signed Statement of Understanding on HSC 1569.696(a)(2) to LPA Brown on 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
Page: 7 of 33
Document Has Been Signed on 06/19/2024 03:52 PM - It Cannot Be Edited


Created By: Melody Brown On 06/19/2024 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GOLDEN HORIZON SENIOR CARE
FACILITY NUMBER: 361881309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not having a record of one (1) medication for Resident #2 (R2) in R2's Medication Administration Record (MAR) at the facility and LPA Brown observed that the facility's dispensing or giving R2's medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on 87465(a)(6) and submit proof of training log to LPA Brown on PLan of Correction (POC) due date.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not updating Resident #9 (R9) Medication Administration Record (MAR) after dispensing/giving R9's medication per physician's directions which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
1
2
3
4
Licensee statedto train all staff on CCR 87465(c)(2) and submit proof of training log to LPA Brown on 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
Page: 8 of 33
Document Has Been Signed on 06/19/2024 03:52 PM - It Cannot Be Edited


Created By: Melody Brown On 06/19/2024 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GOLDEN HORIZON SENIOR CARE
FACILITY NUMBER: 361881309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(4)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (4) Movable bins when used for storing or transporting solid wastes from the premises shall have tight-fitting covers on the containers; shall be in good repair; and shall be rodent-proof unless stored in a room or screened enclosure.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by having a movable waste bin in the kitchen without a cover which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
1
2
3
4
Licensee stated to purchase/obtain movable bin with cover and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87303(i)(1)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not having the required signal system which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
1
2
3
4
Licensee stated to obtain/purchase/install the required signal syatem and submit proof to LPA Brown on Plan of Correction (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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
Page: 9 of 33
Document Has Been Signed on 06/19/2024 03:52 PM - It Cannot Be Edited


Created By: Melody Brown On 06/19/2024 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GOLDEN HORIZON SENIOR CARE
FACILITY NUMBER: 361881309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above not having the required planned activities for the residents at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
1
2
3
4
Licensee stated to submit the required planned Activities/Activity Calendar to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(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
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Based on observation, interview, record review, the licensee did not comply with the section cited above
by not having a completed Physician Report with Physician Signature Date for five (5) of eight (8) residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2024
Plan of Correction
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Licensee stated to submit completed Physician Reports with Physician Signature Date for five (5) residents to LPA Brown on 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
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