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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602369
Report Date: 01/08/2025
Date Signed: 01/08/2025 04:56:47 PM

Document Has Been Signed on 01/08/2025 04:56 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:GOLDEN LIVING HEALTH MANAGEMENT, INC.FACILITY NUMBER:
374602369
ADMINISTRATOR/
DIRECTOR:		ROCIO GRANDAFACILITY TYPE:
740
ADDRESS:3223 DUKE STREETTELEPHONE:
(619) 222-1109
CITY:SAN DIEGOSTATE: CAZIP CODE:
92110
CAPACITY: 113CENSUS: 87DATE:
01/08/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Office Assistant, Yahaira GardunoTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Deficiencies visit. LPA met with Administrator, Rocio Granda and Office Assistant, Yahaira Garduno.

LPA explained the purpose of the visit was to issue deficiencies identified during a complaint investigation that concluded on 01/08/25. A review of records indicated Resident #1 (R1) did not have current documentation on file. R1's Resident Appraisal was dated 04/07/23 and due by April 2024. Once made aware the appraisal was not current, the facility conducted a reappraisal for R1 on 12/10/24. R1 also didn't have an written order for an over the counter (OTC) medication. R1's records reflected a correspondence dated 08/09/24 from the facility addressing R1's physician regarding R1 being able to store and manage their own multivitamins. The physician responded stating R1 can store and manage their own multivitamins. However, the facility did not have a written order on file for R1's multivitamins.

Deficiencies are being cited on the attached LIC 809D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Office Assistant, Yahaira Garduno whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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 01/08/2025 04:56 PM - It Cannot Be Edited


Created By: Natasha Persaud On 01/08/2025 at 02:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2025
Section Cited

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Incidental Medical and Dental Care. For every prescription and nonprescription PRN medication...shall be a signed, dated written order from a physician...and a label on the medication. Both the physician's order and the label...of the following information. This requirement is not met as evidenced by:
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Based on record review the licensee did not ensure 1 out of 87 [R1] residents have current written orders on file, which posed a potential health and safety risk to resident in care.
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Administrator will provide proof of training by POC due date.
Type B
02/05/2025
Section Cited

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Reappraisals. When there is significant change in condition...or once every 12 months, whichever occurs first... share the reappraisal with the resident...and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making.
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Based on record review the licensee did not ensure 1 out of 87 [R1] residents was assessed every 12 months, which posed a potential health and safety risk to resident 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:Robyn Clark
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
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