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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602369
Report Date: 06/19/2024
Date Signed: 06/19/2024 10:00:55 AM


Document Has Been Signed on 06/19/2024 10:00 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
SAN DIEGO RO, 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: 91DATE:
06/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Yahira Gardunio Ramirez, Office Manager/SupervisorTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit to deliver enhanced civil penalties (ECP) and in conjunction conducted this case management visit for background clearance observed during the visit. LPA Lopez identified herself and was granted entry by Yahaira Garduno, Office Manager/Supervisor. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Office Manager/Supervisor Garduno.

During today’s visit, LPA Lopez provided the facility their ECP and checked the associations of the facility staff with the Licensing Information System’s, Facility’s Personnel Report Summary. Staff #1 (S1) was not on the list. According to the Gardian website, S1 is cleared but not associated to the facility. According to S1, they work at the facility Monday through Friday. Based on the evidenced obtained, a deficiency was cited and attached to the LIC809-D page of this report. An immediate civil penalty of $500 was also assessed during today's visit.

An exit interview was conducted with Office Manager/Supervisor Yahaira Garduno and a copy of this report, along with the LIC811, LIC421 and the Licensee/Appeal Rights (LIC 9058 3/22) were provided to the Office Manager/Supervisor at the conclusion of the visit. The signature below confirms the documents were received.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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 06/19/2024 10:00 AM - 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
SAN DIEGO RO, 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: 06/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2024
Section Cited
CCR
87355

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or. This requirement was not met as evidenced by:
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Office Manager/Supervisor agreed to remove S1 from the facility until S1's background clearance was transferred and associated to the facility.
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Based on interviews and records reviewed the facility did not ensure Staff #1 (S1) had a transferred criminal record clearance or was associated to the facility which posed a potential health, safety and personal rights risk to 91 of 91 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: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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