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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602062
Report Date: 06/16/2023
Date Signed: 06/16/2023 02:26:27 PM


Document Has Been Signed on 06/16/2023 02:26 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:GOLDEN SUNSET RESIDENTIALFACILITY NUMBER:
374602062
ADMINISTRATOR:MIGUEL A MALONEFACILITY TYPE:
740
ADDRESS:7541 MILKY WAY POINTTELEPHONE:
(619) 794-2889
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:6CENSUS: 2DATE:
06/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Maricela Vega-Delgado, CaregiverTIME COMPLETED:
01:55 PM
NARRATIVE
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On 6/16/2023, Licensing Program Analyst (LPA), Daniel Pena conducted an unannounced Case Management visit to the facility. LPA was greeted by Caregiver, Maricela Vega-Delgado. LPA introduced himself and explained the purpose of the visit to Ms. Vega-Delgado and was allowed into the facility.

During a complaint investigation, LPA directly observed that the facility did not ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

Based on this information, a deficiency is being cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D. An exit interview was conducted and a copy of the report, Licensee/Appeal Rights (LIC9058 03/22) and LIC811 were provided to Caregiver, Vega-Delgado.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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


Document Has Been Signed on 06/16/2023 02:26 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: GOLDEN SUNSET RESIDENTIAL
FACILITY NUMBER: 374602062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
87506(a)

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Resident Records (a) The licensee shall ensure that...record is maintained for each resident in the facility or...readily available to...licensing agency staff. This requirement was not met as evidenced by:
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Licensee agreed to provide photographic evidence to CCLD proving all current resident records are located at the facility and readily available by POC due date of 6/23/2023.
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Based on LPA observation and staff interviews, licensee did not ensure records were maintained for each resident in the facility or readily available to licensing agency staff. This posed a potential health and safety risk to 5 of 5 residents
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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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2