374604527-4-28-2022-18-AS-TDAN-CDWTAM-20220428143347

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604527
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:34:07 PM

Document Has Been Signed on 04/28/2022 02:34 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 BLOOM VILLA		FACILITY NUMBER:	374604527
ADMINISTRATOR:	VALENCIA, LIZA		FACILITY TYPE:	740
ADDRESS:	725 GOLDEN LANE		TELEPHONE:	(562) 348-2388
CITY:	FALLBROOK	STATE: CA	ZIP CODE:	92028
CAPACITY:	6	CENSUS: 0	DATE:	04/28/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Liza Valencia, Licensee		TIME COMPLETED:	02:45 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	Licensing Program Analysts (LPAs) Tricia Danielson and Chinwe Nwogene conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPAs met with Licensee Liza Valencia. An initial application to operate an Adult Residential Facility (ARF) was received by the Central Applications Bureau (CAB) on 11/15/2021 for a total capacity of six (6) non-ambulatory and one (1) bedridden residents. Fire Clearance was granted for six (6) non-ambulatory and one (1) bedridden residents on 3/1/2022. LPAs observed the following: Structure: Facility was a one story house with four (4) resident bedrooms, one (1) bathrooms, family room, dining area and kitchen. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Each client bedroom will accommodate any non-ambulatory client. Bedroom #1 will accommodate a bedridden resident. Bedrooms #3 and #4 were furnished with bed, chair, closet, adequate lighting, and an operable smoke alarm/carbon monoxide detector. Bedroom #1 was missing a bed and night stand. Bedroom #2 was missing another bed, and clothing storage/dresser for both clients. Bathrooms: The bathrooms had a working toilet, wash basin, and shower. At 1:45 AM, LPAs began testing water temperatures in the client bathroom. LPAs verified water temperature was measured at 91 degrees Fahrenheit. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies were secured in a locked cabinet below the sink. Knives/sharp instruments will be stored in a locked cabinet. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition (CONTINUED ON LIC 812C)

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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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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 BLOOM VILLA	FACILITY NUMBER: 374604527
	VISIT DATE: 04/28/2022

NARRATIVE

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(CONTINUE FROM LIC809)
and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry area with washer and dryer were located in a separate room.
Living/Family room:
There was a family room with safe and adequate seating for all clients as well as working TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in the hallway cabinet.
Yards/Outside:
Fencing secured the entire backyard. All outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property.
Garage:
There was no garage.
Emergency Phone Numbers, and Exit Plan:
Let-Us-No poster, emergency phone numbers, and facility sketch were not observed.
General items:
Two (2) fire extinguisher were charged and mounted in kitchen and near the front door. Smoke alarms/carbon monoxide detectors were tested and were in working order. Client records will be stored in a yet established office in the West wing on the facility. Locked area for medication storage was observed. There were no firearms or ammunition observed at the facility and LPAs were informed the facility will not store firearms or ammunition on the premises. The facility did not have an established First Aid kit with the required components.
Component III was completely during today's visit and a hard copy was provided as well for future reference. Pre-Licensing is not complete at this time. The following corrections must be made in order to meet licensing requirements:
emergency flashlights
emergency food and water supply
signal system in client rooms
adequate clothing storage/dressers in room #1
gates to side and front of home must be self latching and locks must be removed
(CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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 BLOOM VILLA	FACILITY NUMBER: 374604527
	VISIT DATE: 04/28/2022

NARRATIVE

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(CONTINUED ON LIC 809C)
required postings must be posted
patio furniture must be assembled
patio covering must be obtained
obtain a bed for room #1 and an additional bed for room #2
water temperature must measure between 105 and 120 degrees Fahrenheit

An exit interview was conducted and a copy of this report was provided.

Please note: the resident/client living area of this facility is solely permitted in the central and East portions of the home. The West wing remains under construction to met fire department requirements for future use.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC809 (FAS) - (06/04)

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