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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604313
Report Date: 07/29/2024
Date Signed: 07/29/2024 11:14:55 AM


Document Has Been Signed on 07/29/2024 11:14 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:GOLDEN HOUSE RESIDENCE #24FACILITY NUMBER:
374604313
ADMINISTRATOR:KARATAS, ELOISA C.FACILITY TYPE:
740
ADDRESS:24 VIA LARGA VISTELEPHONE:
(760) 295-4141
CITY:BONSALLSTATE: CAZIP CODE:
92003
CAPACITY:6CENSUS: 6DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Eloisa Karatas, AdministratorTIME COMPLETED:
11:25 AM
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On 07/29/24 Licensing Program Analyst (LPA) Javina George conducted an unannounced visit for the purpose of conducting a 1 year required visit/annual inspection. LPA George met with Administrator Eloisa Karatas and informed her of the purpose of today's visit.

The facility is licensed to serve 6 non ambulatory, of which 1 may be bedridden, aged 60 and over resident's. The facility has an approved hospice waiver for 4, with 4 residents currently receiving hospice services.

Infection Control: LPA George observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Staff were observed practicing good hand hygiene (washing hands) before providing care to the residents.

Physical Plant: LPA toured the interior and exterior of the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. There are 6 bedrooms and 3 bathrooms, as well as a caregivers quarters upstairs. The facility was observed to have the required furniture and linen to be present and in good condition in resident bedrooms. The exits are free from obstruction and that there is plenty of space for activities. There are no pools or bodies of water on the premises.

Records Review: Staff Records: LPA observed that there are sufficient staff present to meet the needs of residents. LPA George additionally confirmed that there is an Administrator present with a valid administrator's certificate that expires on 08/11/25. LPA George observed for all staff present to have obtained criminal record clearance and were associated to the facility and have training to perform their required duties. All staff present at have current CPR/First Aid Certification.

Resident Records: A review of 3 residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GOLDEN HOUSE RESIDENCE #24
FACILITY NUMBER: 374604313
VISIT DATE: 07/29/2024
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Food Services: The kitchen and dining area to be maintained in a clean and healthful manner. LPA observed for there to be individual trays that LPA George observed the facility to have the required amount of 7 day supply non-perishable and a two supply perishable food items.

Medication: Resident medication was observed to be locked in the medication cart and inaccessible to residents. A review of medication revealed that the medication is being given as prescribed as evidenced by the electronic Medication Authorization Record (MAR) and medication (bubble packs and or pill bottle).

Emergency Disaster Preparedness: The facility has an Emergency Disaster Plan on file and conducts regular disaster drills on a quarterly basis. The last drill was conducted on 06/24/24. The smoke and carbon monoxide detectors were tested and were found to be operable. The facility has fully charged fire extinguishers. There are no known guns or ammunition on the premises. The hot water was tested and was found to be within regulatory limit measuring at 106.8 degrees Fahrenheit.

Based on today's inspection no deficiencies were issued.

An exit interview was conducted and a copy of this report, were provided to Eloisa Karatas.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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