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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607201
Report Date: 10/24/2022
Date Signed: 10/24/2022 04:46:45 PM

Document Has Been Signed on 10/24/2022 04:46 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GOLDEN CITY HOME CAREFACILITY NUMBER:
197607201
ADMINISTRATOR:ANTONIA DIONISIOFACILITY TYPE:
740
ADDRESS:2451 W. 230TH STREETTELEPHONE:
(310) 325-1995
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 6DATE:
10/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:ANTONIA DIONISIOTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lourdes Montoya initiated a Case Management - Deficiency visit to document a deficiency observed during an unrelated complaint visit. LPA met with Administrator Antonia Dionisio and the purpose of the visit was explained.

On 10/24/2022, LPA Montoya observed the kitchen cabinets and counter top are greasy. The garage is cluttered.

Title 22 Division 6 Chapter 1 Article 6 is being cited, please see LIC809D.

An exit interview was conducted and a plan of correction was developed. A copy of this report and appeal rights were provided to Administrator Antonia Dionisio.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/24/2022 10:20 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/24/2022 10:16 PM


Created By: Lourdes Montoya On 10/24/2022 at 03:47 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN CITY HOME CARE
FACILITY NUMBER: 197607201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2022
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times.
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Administrator shall degrease and clean the kitchen cabinets and counter top and organize the garage. Administrator shall submit a proof of correction to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date 11/15/2022.
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On 10/24/2022, LPA Montoya observed the kitchen cabinets and countertop are greasy. The garage is cluttered. This poses a potential health, safety and/or personal rights risk to residents in care.
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This report is amended to change the citation 87303(a) of Title 22 and to change the POC due date to 11/15/2022.

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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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022


LIC809 (FAS) - (06/04)
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