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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602369
Report Date: 06/22/2022
Date Signed: 06/23/2022 08:44:07 AM


Document Has Been Signed on 06/23/2022 08:44 AM - 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 LIVING HEALTH MANAGEMENT, INC.FACILITY NUMBER:
374602369
ADMINISTRATOR:ROCIO GRANDAFACILITY TYPE:
740
ADDRESS:3223 DUKE STREETTELEPHONE:
(619) 222-1109
CITY:SAN DIEGOSTATE: CAZIP CODE:
92110
CAPACITY:113CENSUS: 86DATE:
06/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Administrator Rocio GrandaTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to follow up on an event which licensee self-reported to the Community Care Licensing Division San Diego Regional Office (RO). LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Rocio Granda.

The RO received a LIC624 Unusual Incident Report regarding Resident #1 (R1) being absent without leave from the facility (AWOL) [see LIC 811 Confidential Names list for a description of R1]. The report indicated that R1 was last seen at a McDonald’s restaurant on 06-17-2022, and as of the evening of 06-17-2022, had not yet returned to the facility. Licensee notified R1’s case manager and law enforcement, who helped with trying to locate R1.

During today's visit, LPA briefly toured the facility, performed a welfare check on R1, obtained copies of pertinent administrative and care records, and interviewed R1 and staff. It was revealed that on the morning of 06-18-2022, R1 returned to the facility on their own, unharmed. No deficiencies were cited during today’s visit.

An exit interview was conducted with Granda, to whom a copy of this report, the Confidential Names list (LIC 811), and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
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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