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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602062
Report Date: 07/01/2021
Date Signed: 07/02/2021 09:21:00 AM

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:6CENSUS: 4DATE:
07/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Administrator Miguel "Michael" MaloneTIME COMPLETED:
07:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted a Case Management visit to cite deficiencies identified during an unannounced Complaint Investigation. LPA introduced himself, stated the purpose of the visit, and was granted entry by Caregiver Perla Martinez-Gutierrez. Administrator Miguel “Michael” Malone arrived during the visit. All staff encountered had a current criminal record clearance.

LPA conducted a complaint investigation visit on 07/01/2021 and observed the following deficiencies:

-Staff #1 (S1) (see LIC 811 Confidential Names List for identification of S1) spoke Spanish but was not able to communicate in English. At the time, there were no other staff on duty to assist or translate for S1. It was necessary for LPA to use Google Translate on his phone to communicate with S1. All residents in care did not speak Spanish and exhibited memory loss and disorientation; each was unable to communicate with S1.

-There were containers of furniture polish, glass cleaner, air freshener, and other solvents on top of a common area hallway counter. In an unlocked hallway cabinet were two can of air freshener and one can of disinfectant. On top of the bathroom counter in Bedroom #4 was a cleaning solvent containing bleach. Facility staff locked away each of the above items during the visit.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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 4
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
VISIT DATE: 07/01/2021
NARRATIVE
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[CONTINUED FROM LIC 809]

-A sharp cooking knife was left unlocked and accessible to residents. In the backyard, on the ground, was a tray containing two pairs of metal scissors (non-safety type), metal gardening shears, and a metal trowel. In an unlocked shed in the backyard were 3 six-gallon and 2 one-gallon containers of paint, containers of heavy duty epoxy, and miscellaneous rusted metal tools, to include a two-handed pair of gardening shears and a handsaw. Facility staff locked away each of the above items during the visit.

-There was an opened container of Swiffer Wet Jet cleaning pads (saturated in chemical) stored beside non-perishable foods in the kitchen pantry, which was unlocked. Facility staff moved the pads to a locked garage during the visit.

Deficiencies are being cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations and listed on an LIC 809-D. An exit interview was conducted with Malone, to whom a copy of this report, the LIC 811, and the Licensee/Appeal Rights (LIC 9058 01/16) were provided via E-mail.

SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 07/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2021
Section Cited

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Care of Persons with Dementia: The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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This requirement is not met as evidenced by: Based on observation on 7/1/21, a knife and metal tools were unlocked and accessible to 4 of 4 residents diagnosed with dementia. This poses an immediate safety risk to residents in care.
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for staff to do a facility walkthrough twice per day to check for hazards, and to train all staff on it by 07-25-21. Administrator will send LPA a copy of S1's counseling, and a written pledge to conduct the training by 07-02-21.
Type A
07/02/2021
Section Cited

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Care of Persons with Dementia: The following shall be stored inaccessible to residents with dementia: (2)...toxic substances such as…cleaning supplies and disinfectants.
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This requirement is not met as evidenced by: Based on observation on 7/1/21, cleaning chemicals and paints were unlocked and accessible to 4 of 4 residents diagnosed with dementia. This poses an immediate safety risk to residents in care.
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for staff to do a facility walkthrough twice per day to check for hazards, and to train all staff on it by 07-25-21. Administrator will send LPA a copy of S1's counseling, and a written pledge to conduct the training by 07-02-21.
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: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: 07/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2021
Section Cited

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Storage Space: Disinfectants, cleaning solutions…shall not be stored in food storage areas or in storage areas used by or for clients.
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This requirement is not met as evidenced by: Based on observation on 7/1/21, a cleaning chemical was stored on a high top shelf, amongst food in the facility’s unlocked dry food pantry. This poses a potential safety risk to residents in care.
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for staff to do a facility walkthrough twice per day to check for hazards, and to train all staff on it by 07-25-21. Administrator will send LPA a copy of S1's counseling, and a written pledge to conduct the training by 07-02-21.
Type B
07/31/2021
Section Cited

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Personnel Requirements – General: All personnel shall…have…(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.
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The requirement is not met as evidenced by: Based on observation and interviews, S1 and residents were unable to communicate with each other. This poses a potential personal rights risk to residents 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: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2021
LIC809 (FAS) - (06/04)
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