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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602062
Report Date: 05/28/2024
Date Signed: 05/28/2024 05:23:28 PM


Document Has Been Signed on 05/28/2024 05:23 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, 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:0CENSUS: 0DATE:
05/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:N/A. Report Certified Mailed to Licensee.TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted a Case Management process to cite deficiencies identified during a separate complaint investigation. Since the facility ceased operations on 01/23/2024 due to Licensee-Initiated Closure, this report was delivered to the Licensee via USPS certified mail.

Records review and manager interview showed Licensee had a partially filled-out LIC602 Physician’s Report on file for Resident #1 (R1). However, this form was not signed by R1’s physician and was therefore incomplete and not fully valid. There was no other equivalent Medical Assessment on file for R1 meeting the regulatory requirement.

During CCLD’s investigation, LPA asked for a copy of the facility’s sample food menu, then allowed additional days for the request to be filled. LPA was ultimately notified by facility management that Licensee did not have a sample food menu to show.

Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Since the facility has closed and ceased operations, no Plans of Correction were formed with the Licensee.

A copy of this report, the LIC9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the Licensee’s last known address via USPS certified mail.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2024
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 2


Document Has Been Signed on 05/28/2024 05:23 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: GOLDEN SUNSET RESIDENTIAL
FACILITY NUMBER: 374602062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2024
Section Cited
CCR
87458(a)

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87458 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.”
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Since the facility has closed and ceased operations, no Plan of Correction was formed with the Licensee.
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This requirement was not met, as evidenced by: Based on records review and interviews, for 1 of 4 residents (R1) in care, licensee did not obtain and keep on file, documentation of a medical assessment, signed by a physician. This posed a potential health, safety, and personal rights risk to persons in care.
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Type B
05/28/2024
Section Cited
CCR87555(b)(6)(16)

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87555 General Food Service Requirements: “(b) The following food service requirements shall apply: (6) …Facilities licensed for less than sixteen (16) residents shall maintain a sample menu in their file. Menus shall be made available for review by the residents or their designated representatives and the licensing agency upon request.”
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Since the facility has closed and ceased operations, no Plan of Correction was formed with the Licensee.
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This requirement was not met, as evidenced by: Based on records review and interview, Licensee did not make available its sample food menu upon the licensing agency’s request. This posed a potential health and personal rights risk to persons in care.
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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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2024
LIC809 (FAS) - (06/04)
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