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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366405789
Report Date: 12/14/2022
Date Signed: 12/14/2022 02:36:37 PM


Document Has Been Signed on 12/14/2022 02:36 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:GOLDEN GUEST HOMEFACILITY NUMBER:
366405789
ADMINISTRATOR:GALASINAO, ADELAIDAFACILITY TYPE:
740
ADDRESS:25070 DAISY AVENUETELEPHONE:
(909) 796-0882
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: DATE:
12/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mercy Corpuz, CaregiverTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Amber Coleman made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA rang doorbell, staff member, Mercy Corpuz, (S1) answered the door greeted LPA. LPA introduced self and stated purpose of the visit. S1 invited LPA inside facility and contacted the Administrator who later arrived during visit. LPA signed in at table and observed PPE and hand sanitizer offered to staff, visitors and residents. LPA was informed the current census is 6. There are currently no residents with COVID at this time.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has put in place. LPA observed signs for infection control and policy posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) made available in each bathroom and kitchen.

The facility staff has a plan to manage Covid-19 symptoms, which includes staff monitoring residents regularly for any changes in condition, which includes daily temperature checks. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses. All facility staff are responsible for cleaning and disinfecting the highly touched surfaces during their shift.

Fire and Carbon Monoxide Alarms were tested and found to be in proper working condition. Fire extinguisher was full and last inspected 4/14/2022.

The outdoor and indoor hallways were free of obstruction. The client rooms had the required furniture and sufficient lighting. The bathrooms can accommodate the needs for bathing and showers and have non-slip flooring. The facility had a supply of additional linen and extra hygiene items for the clients. LPA measured the hot water temperature measured at 120 degrees F. LPA observed hand sanitizer throughout the facility and a 30- day supply of PPE.



During today's visit, LPA observed a number of power tools and construction materials in the backyard. Technical violations (TVs) are being issued for aforementioned concerns due to no notification of alternations of building.
An exit interview was conducted where this report and LIC9102TV were discussed and provided to the Administrator.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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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