371881362-10-10-2023-18-AS-JSRS-CWGRD8-20231010125532

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 371881362
Report Date: 10/10/2023
Date Signed: 10/10/2023 12:55:38 PM

Document Has Been Signed on 10/10/2023 12:55 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GOLDEN SUNSET VILLA SENIOR LIVING		FACILITY NUMBER:	371881362
ADMINISTRATOR:	LU, MARK		FACILITY TYPE:	740
ADDRESS:	1995 SUNSET DRIVE		TELEPHONE:	(858) 397-8381
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92025
CAPACITY:	6	CENSUS: 6	DATE:	10/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Mark Lu, Administrator		TIME COMPLETED:	01:00 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 Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to conduct an annual licensing inspection. LPA was met by Claudia Cain, Caregiver, and was granted entry into the facility. LPA met with Mark Lu, Licensee/Administrator, and discussed the purpose of the visit. A tour of the facility was conducted inside and out. LPA, accompanied by staff, conducted a general overall inspection, which included but was not limited to the following: Facility physical plant, food service, medication management, record review and facility administration. The facility is licensed to serve six (6) elderly residents, six (6) of whom may be non-ambulatory, and one bedridden. A Hospice waiver is approved for six (6) residents. During today's inspection, LPA observed the following: Indoor and outdoor passageways were observed to be free from obstruction. There are no pools or bodies of water. Per Licensee, there are no firearms or other dangerous weapons in the facility. Poisons and cleaning agents were observed to be secured and inaccessible to residents in care. Facility fire clearance is maintained in conformity with State Fire Marshal regulations. LPA toured every room in the facility. Rooms designated as resident rooms had the required furnishings and sufficient lighting available. Licensee provided each resident with clean linen, in good repair, and sufficient hygiene products for personal use. The hot water temperature measured at 105.4 degrees F. The facility had a functioning carbon monoxide detector, multiple smoke detectors, and an operable fire extinguisher. The facility was stocked with a two-day supply of perishable food items and a seven-day supply of nonperishable food items. Staff records were reviewed and contained CPR/First Aid training, Health Screening Reports, and annual training. CONT'D ON LIC 809C...

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN SUNSET VILLA SENIOR LIVING	FACILITY NUMBER: 371881362
	VISIT DATE: 10/10/2023

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CONT'D FROM LIC 809....

Resident records were reviewed and had a current Physician's Report, Resident Appraisal, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication and Destruction Records. Medications were stored in a locked cabinet and were labeled and maintained in compliance with label instructions. Drills are conducted quarterly. The last drill was conducted on 10/2/2023. Licensee Mark Lu's administrator's certificate expires 4/22/2024.

No deficiencies were observed during today's visit. This report was discussed with Licensee. A copy of this report, along with Licensee/Appeal Rights, was provided at the conclusion of the visit.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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