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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602369
Report Date: 04/29/2022
Date Signed: 05/02/2022 12:23:59 PM

Document Has Been Signed on 05/02/2022 12:23 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: 83DATE:
04/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Medication Technician Supervisor, Yahaira Garduno TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Natasha Persaud conducted a Case Management - Incident visit. LPA met Medication Technician Supervisor, Yahaira Garduno and stated the purpose of the visit was to follow up on an incident report. LPA also contacted Administrator, Rocio Granda via telephone to discuss the incident.

On 04/28/22, the facility submitted a self-reported incident involving Resident #1 (R1). The incident report stated R1 left the facility on 04/27/22 and did not return. While out in the community, R1 was transported to the hospital. The facility contacted R1's responsible party and local law enforcement.

During today's visit, LPA briefly toured the facility, obtained records and interviewed staff and residents. A review of records indicated R1 does not have a current Resident Appraisal on file. The last appraisal on file for R1 was dated 11/29/18. A deficiency was issued and cited on the attached 809D.

An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Medication Technician Supervisor, Yahaira Garduno whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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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Document Has Been Signed on 05/02/2022 12:23 PM - It Cannot Be Edited


Created By: Natasha Persaud On 04/29/2022 at 04:27 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: 04/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2022
Section Cited
CCR
87463(c)

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Reappraisals. The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff...if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first...87467, Resident Participation in Decision Making.
This requirement is not met as evidenced by:
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Administrator agreed to complete a resident appraisal for R1 and ensure appraisals are completed annually or sooner if there's a change in condition.
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Based on record review, the licensee did not complete a Resident Appraisal for 1 out of 83 residents. This poses 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022


LIC809 (FAS) - (06/04)
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