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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607206
Report Date: 03/13/2023
Date Signed: 03/13/2023 01:37:43 PM

Document Has Been Signed on 03/13/2023 01:37 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 CARE LIVING, INC.FACILITY NUMBER:
197607206
ADMINISTRATOR:ANGELIQUE S. GRADNEYFACILITY TYPE:
740
ADDRESS:2052 REDONDELA DRIVETELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 4DATE:
03/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Rachel LugtuTIME COMPLETED:
01:45 PM
NARRATIVE
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On 03/13/23, Licensing Program Analyst (LPA) Ernand Dabuet initiated a case management visit to the above facility. Today’s case management visit was conducted with Rachel Lugtu care staff and spoke with Administrator Catherine Espino via telephone, and today's visit was explained.

The purpose of the visit was to follow up on a Proof of Correction in association with complaint # 11-AS-20201222113312. LPA inspected the facility. During the inspection, LPA observed room #1 for resident #1 (R1) did not have a closet space available for personal items. LPA identified a closet door with a hanging padlock utilized for staff personal clothing, hygiene supplies, and three 3) clothing items that belong to (R1). According to Lugtu, the resident was prevented from accessing (R1's) clothing items as the resident would take the items and wash them in the bathroom and they were concerned for (R1's) safety.

An interview with administrator Espino expressed she was not informed by the care staff that had made these modifications in (R1's) room. A resident not having access to personal items is of Title 22 Section 87468.1 Personal Rights of Residents in All Facilities and not having a closet space and is a violation of Title 22 Section 87307 Personal Accommodations and Services.

Based on the interviews and observation, the preponderance of evidence standard has been met.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099-D).

An exit interview was conducted with Rachel Lugtu, copy of the report and appeal rights were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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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Document Has Been Signed on 03/13/2023 01:37 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 03/13/2023 at 01:09 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN CARE LIVING, INC.
FACILITY NUMBER: 197607206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2023
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Licensee & Administrator shall read Title 22, Section 87468.1 and send a written statement to CCLD by the POC date that they will ensure that all residents in care are provided Personal Rights. A plan to address the behavior without violating the resident's rights. POC is due to the CCLD/El Segundo ASC Office by the POC date of 03/27/23,.
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This requirement is not met as evidenced by: Resident #1 was not accorded a comfortable accomdations and did not have access to to personal clothing items. This violation is a potential risks to resident in care.

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Type B
03/27/2023
Section Cited
CCR87307(E)

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87307 Personal Accommodations and Services (E) Portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings. A minimum of eight (8) cubic feet (.743 cubic meters) of drawer space per resident shall be provided.
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Licensee & Administrator shall read Title 22, Section 87307 and send a written statement to CCLD by the POC date that they will ensure that all residents in care are provided a comfortable enviroment. A plan to address the missing closet space. POC is due to the CCLD/El Segundo ASC Office by the POC date of 03/27/23,.
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This requirement is not met as evidenced by: Resident #1 was not accorded a comfortable accomdations and did not have a closet space as required by Title 22 Sec 87307. This violation is a potential risks to resident in care.
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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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023


LIC809 (FAS) - (06/04)
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