374604313-7-20-2023-18-AS-JSRS-CTWT7W-20230720142926

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604313
Report Date: 07/20/2023
Date Signed: 07/20/2023 02:31:28 PM

Document Has Been Signed on 07/20/2023 02:31 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GOLDEN HOUSE RESIDENCE #24		FACILITY NUMBER:	374604313
ADMINISTRATOR:	KARATAS, ELOISA C.		FACILITY TYPE:	740
ADDRESS:	24 VIA LARGA VIS		TELEPHONE:	(760) 295-4141
CITY:	BONSALL	STATE: CA	ZIP CODE:	92003
CAPACITY:	6	CENSUS: 6	DATE:	07/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Eloisa Karatas, Administrator		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On July 20, 2023, Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived unannounced at the facility to conduct an annual inspection. LPA was greeted and granted entry by Administrator, Eloisa Karatas who was informed of the purpose of the visit. Co-Administrator Yusuf Karatas joined as well. The facility is licensed for six non-ambulatory, one bedridden, and has approved hospice waiver for four residents. At the time of visit there were one staff and six residents present. One staff and two residents was interviewed. LPA toured the facility inside and out. The outside area is free from obstructions and no bodies of water were observed. The facility is two stories and has six bedrooms and three bathrooms downstairs. LPA observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility. LPA observed bathrooms to be clean with grab bars and hot water was measured at 105.6 degrees Fahrenheit. The temperature inside the facility was observed to be 78 degrees. The laundry room was observed to be clean, equipped with washing machine and dryer. LPA observed laundry solutions are adequately secured in a locked cabinet. LPA observed kitchen to be clean and food stored in a safe and healthful manner. There are seven days non-perishable and two days of perishable food supply present. LPA observed knives stored in a locked cabinet and cleaning solutions are adequately stored under the kitchen sink. LPA observed the dining and living area to be clean and furniture in good condition. LPA observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguishers (3) and found them all to be in compliance and record to be up to date.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN HOUSE RESIDENCE #24	FACILITY NUMBER: 374604313
	VISIT DATE: 07/20/2023

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Continued From LIC809

Carbon monoxide & smoke detectors were tested and functioning properly. Emergency drills are conducted quarterly. All required postings, were posted near the entryway and throughout the facility.

LPA observed medications were labeled and stored inside of a locked medication cabinet. The first aid kit was complete.

LPA inspected four staff and six client records. All staff have a criminal record clearance in file and are confirmed as being associated with the facility.

LPA inspected medications and medications appear to be dispensed appropriately according to the physician's orders.

No deficiencies were observed during today's annual inspection. An exit interview was conducted and a copy of the report and LIC 811 was provided to Administrators Eloisa Karatas and Yusuf Karatas.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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