374604314-11-20-2024-18-AS-VMIN-DB7NAW-20241120091812

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604314
Report Date: 11/08/2024
Date Signed: 11/20/2024 09:18:21 AM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/20/2024 09:18 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GOLDEN HOUSE RESIDENCE #21		FACILITY NUMBER:	374604314
ADMINISTRATOR/ DIRECTOR:	KARATAS, ELOISA C.		FACILITY TYPE:	740
ADDRESS:	21 VIA ALTA VISTA		TELEPHONE:	(760) 295-4141
CITY:	BONSALL	STATE: CA	ZIP CODE:	92003
CAPACITY: 6		CENSUS: 5	DATE:	11/08/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:48 AM
MET WITH:	ADMINISTRATOR, ELOISA C. KARATAS		TIME VISIT/ INSPECTION COMPLETED:	09:13 AM

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THIS IS A DUPLICATE OF THE ANNUAL THAT WAS CONDUCTED on 11/08/2024.
On November 08, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, Eloisa Karatas. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for six Elderly Adults and is currently operating at a capacity of (5) five Elderly Adults (740).

LPA Mixson toured the facility along with the Administrator and made observations pertaining to the annual visit. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. Additionally, there were no bodies of water on the premises. The facility is a single-story home located at 21 Via Alta Vista Bonsall, CA. 92003.

Physical Plant: The facility phone number is (760) 294-4141 and it is operable. LPA Mixson observed the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations at. The bathrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and the PUB 475. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit.

Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. The overall facility is clean, the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit. Administrator informed LPA there were safety lights for night throughout the facility.

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, and sharp items are locked.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN HOUSE RESIDENCE #21	FACILITY NUMBER: 374604314
	VISIT DATE: 11/08/2024

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Care & Supervision/Administration: Adequate staff are present for the supervision of resident in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses a current administrator’s certificate with an expiration date of 08/28/2026.

Records Reviewed and Resident/Staff Files: LPA reviewed staff files and reviewed the facility's staff schedule. The staff files reviewed has criminal clearance and updated training along with First Aid Certification. LPA reviewed five resident files files reviewed were current and up to date on required paperwork.

Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards, and was completed every three months 08/02/2024. Was conducted by Yusuf Karatas.

Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures.

There were no deficiencies observed or cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted where a copy of this report was discussed and given to Administrator, Eloisa C. Karatas.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC809 (FAS) - (06/04)

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