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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602369
Report Date: 10/11/2022
Date Signed: 10/12/2022 08:41:48 AM

Document Has Been Signed on 10/12/2022 08:41 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:
10/11/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Administrator, Rocio GrandaTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst, (LPA), Natasha Persaud conducted an unannounced Case Management - Legal/Non-Compliance visit. The purpose of the visit was to conduct an inspection to ensure ongoing compliance with regulations and laws and ensure the health and safety of residents in care. LPA met with Administrator, Rocio Granda.

During today’s visit, LPA briefly toured the facility, observed residents in care, reviewed records, and provided consultation regarding Title 22 requirements. LPA discussed the following regulations with the administrator to ensure compliance: Care of Persons with Dementia; Incidental Medical & Dental Care; Additional Personal Rights of Residents in Privately Operated Facilities; Reappraisals; and Reporting Requirements. The administrator was debriefed on the regulations and there is an understanding of the regulations.

A review of resident records indicated Resident #1, Resident #2, and Resident #3 do not have a current resident appraisal on file. The appraisal is required to ensure the facility is meeting the resident's care needs.

Based on today’s inspection, a deficiency was observed and cited on the attached LIC 809D. An exit interview was conducted and a copy of this report along with Licensee's Appeal Rights (LIC 9058 01/16) were provided to Administrator, Rocio Granda whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names to identify Residents #1, #2, and #3]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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 10/12/2022 08:41 AM - It Cannot Be Edited


Created By: Natasha Persaud On 10/11/2022 at 02:11 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: 10/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2022
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...when there is significant change in the resident’s condition, or once every 12 months...Decision Making.
This requirement is not met as evidenced by:
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Administrator stated it was an oversight and the Reappraisals for the 3 residents will be completed and copies will be submitted as proof of correction.
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Based on record review, the licensee did not ensure resident appraisals were on file for 3 out of 86 residents. This poses a health and safety risk to 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022


LIC809 (FAS) - (06/04)
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