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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602400
Report Date: 09/14/2022
Date Signed: 09/14/2022 02:13:56 PM

Document Has Been Signed on 09/14/2022 02:13 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GOODEN RESIDENTIAL WELLNESS CENTER, THEFACILITY NUMBER:
198602400
ADMINISTRATOR:MITCHELL, CORY BFACILITY TYPE:
772
ADDRESS:378 N EL MOLINO AVETELEPHONE:
(626) 657-8853
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 6CENSUS: 6DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:03 AM
MET WITH:Ayisha Flores - Program Technician
Cory Mitchell - Director of Compliance 		TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on the infection control domain, food, and medication review. LPA met with Ayisha Flores Program Technician and explained the reason for the visit. Cory Mitchell and Candance Chavez Mental Health Program Lead arrived 15 minutes later.

The facility is an adult residential licensed to serve a total of six (6) developmentally disabled adults between the ages of 18 to 59. Facility is a two story home consisting of a living room, kitchen, formal dining room, activity room, an office downstairs/upstairs, three bedrooms, two full baths and 1/2, laundry room, 2 (two) supply rooms/closets, patio with detached garage. No large bodies of water were observed in the property.

LPA Flores and Cory Mitchell Director of Compliance conducted a tour of the facility and observed the following: Living/dining/activity room is clean and in good repair. Kitchen is clean and in good repair, no sharps were observed, cleaning supplies are maintain lock in the basement. Sufficient food for snacks was observed. Facility receives meals from main house delivered daily per facility's plan of operation. All bedrooms have sufficient lighting, furniture, and bedding supplies. Bathrooms were observe stock with hand soap and paper towels, water temperature was tested as follow; bathroom #1(B1) tested at 118.1 degrees F., and bathroom #2(B2) tested at 121.4 degrees F., which is not within the required 105-120 degrees F. Garage and basement are inaccessible to clients. Smoke detectors were tested and are in working condition. Carbon monoxide detectors were observed throughout the facility. Fire extinguishers were observed and last checked on 5/10/22. Medication is kept locked in downstairs office. LPA reviewed medication and files for 3 clients, clients #1(C1) and #2(C2) have PRN medication without a physician's order on file. Staff files were reviewed and staff #2(S2) does not have a health-screening on file, and staff #3(S3) does not have a health-screening, or TB test clearance on file.

(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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Document Has Been Signed on 09/14/2022 02:13 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/14/2022 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOODEN RESIDENTIAL WELLNESS CENTER, THE
FACILITY NUMBER: 198602400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onobservation, the licensee did not comply with the section cited above in bathroom #2 water temperature tested at 121.4 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Licensee will ensure to maintain water temperature at the required temperature of 105 -120 degrees F., at all times, will certify via LIC 9098, and submit to the department by POC date 9/15/22.
Type A
Section Cited
CCR
81705(b)(6)(D)
Health Related Services: (b) Clients shall be assisted as needed with self - administration of prescription and non-prescription medications. (6) If the client... facility staff designated by the licensee...(D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated, written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 3 clients medication review, C1 and C2 had PRN medication assisted with without a prescription provided by a physician or label which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Licensee is to ensure there is a physician's order for PRN medicaiton on file and submit a copy of the physician's order for PRN medication to the department by POC date 9/15/22.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/14/2022 02:13 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/14/2022 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOODEN RESIDENTIAL WELLNESS CENTER, THE
FACILITY NUMBER: 198602400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81066(c)(10)
Personnel Records
(c) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 81065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff files review, S2 and S3 do not have a healthscreening on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Licensee will ensure S2 and S3 obtain a healthscreening and submit a copy to the department by POC date 9/21/22.
Type B
Section Cited
CCR
81066(c)(11)
Personnel Records
(c) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 81065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply witht he section cited above in 1 out of 3 staff files review, S3 does not have a TB test clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Licensee is to ensure S3 obtains a TB test clearance and submit a copy to the department by POC due date 9/21/22.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


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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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOODEN RESIDENTIAL WELLNESS CENTER, THE
FACILITY NUMBER: 198602400
VISIT DATE: 09/14/2022
NARRATIVE
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LPA did not observed signs regarding COVID precautions, cough and sneeze etiquette posted at the facility. No screening station, no visitor/staff/outing screening conducted, or logs maintained. N95s were observed, but no additional PPE supplies available at the facility. Per Director of Compliance staff have not been fit tested for N95 use.

Deficiencies have been noted on LIC 809D per Title 22, Division 6, Chapter 2 and Technical Advisories were provided regarding infection control.

Exit interview was conducted with Cory Mitchell Director of Compliance and a copy of this report, LIC 809D, technical advisories notes, and appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC809 (FAS) - (06/04)
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