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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604314
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:57:51 PM


Document Has Been Signed on 11/07/2023 02:57 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:GOLDEN HOUSE RESIDENCE #21FACILITY NUMBER:
374604314
ADMINISTRATOR:KARATAS, ELOISA C.FACILITY TYPE:
740
ADDRESS:21 VIA ALTA VISTATELEPHONE:
(760) 295-4141
CITY:BONSALLSTATE: CAZIP CODE:
92003
CAPACITY:6CENSUS: DATE:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:ADMINISTRATOR, ELOISA KARATASTIME COMPLETED:
03:08 PM
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On November 07, 2023, Licensing Program Analyst (LPA), Venus Mixson made an unannounced visit to the facility to conduct an annual licensing inspection, and met with the Administrator, Eloisa Karatas The LPA introduced herself and stated the purpose of the visit.

LPA Mixson toured the facility along with the Administrator, and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is licensed to serve six residents; ages 60 and above; three of whom may be non-ambulatory and ambulatory, currently there are five residents and two staff. The facility has an approved hospice waiver for one resident.
Physical Plant: The facility is a two story town home type with seven bedrooms, and five bathrooms, located at 21 Via Alta Vista, Bonsall, CA. 92003 The facility phone number is (760)295-4141, and is operable. The LPA observed the residents bedrooms, and they are equipped with required furniture as per Title 22. The LPA inspected the facility bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required postings such as; the Ombudsman poster, "If you See Something, Say Something" and the "Personal Rights" postings were posted at the front door. The cleaning supplies and sharp items were kept locked and inaccessible to the residents. There was a designated area for the resident and staff files. Medications: were reviewed with the Administrator and were locked and inaccessible to residents. The overall facility is clean, welcoming, and the furniture is in good condition. The facility air conditioning and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly. Care & SupervisionThe facility has sufficient staff, two caregivers at the time of this visit, and the staff were attending to the residents. Records Review: The LPA reviewed five resident files, two staff files, and reviewed previous CCL forms. There were no Title 22, Division 6 Regulation violations observed and/or cited during todays visit.
An exit interview was conducted and a copy of this report was given to the Administrator, Eloisa Karatas.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
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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