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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602369
Report Date: 02/23/2024
Date Signed: 02/23/2024 03:05:48 PM


Document Has Been Signed on 02/23/2024 03:05 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 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: DATE:
02/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Wellness Director Diana RodriguezTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an announced case management visit to cite deficiencies observed during a complaint visit that are unrelated to the complaint allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Wellness Director Diana Rodriguez.

During the unrelated complaint visit, LPA observed Staff 1 (S1) working at the facility [Caregiver Supervisor was given an LIC811 Confidential Names List to identify S1]. Review of the Department's personnel record for individuals associated to the facility revealed that S1 was not associated to the facility. Interviews with S1 revealed that S1 has been working at the facility for more than 5 days. Therefore, a deficiency regarding staff association is being cited per California Code of Regulations Title 22 and noted on the attached LIC809-D page. Additionally, a civil penalty in the amount of $500 is being issued on an LIC421BG.

An exit interview was conducted with Caregiver Supervisor Mina Ramirez, whose signature below confirms receipt of a copy of this report (LIC809), LIC811, LIC421BG, and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
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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Document Has Been Signed on 02/23/2024 03:05 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 LIVING HEALTH MANAGEMENT, INC.
FACILITY NUMBER: 374602369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance. This requirement has not been met as evidenced by:
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During the visit, LPA Ruiz confirmed that S1 left the facility. S1 must be background check cleared and associated to the facility prior to returning to work.
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Based on interviews and records review, the licensee did not ensure that S1's criminal background clearance was transferred to the facility prior to working. This poses an immediate safety risk to 97 of 97 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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