197607644-2-13-2023-11-AS-WGIS-CNQ2Y3-20230203164803

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607644
Report Date: 02/03/2023
Date Signed: 02/13/2023 03:07:14 PM

Document Has Been Signed on 02/13/2023 03:07 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:	A GOLDEN HORIZON		FACILITY NUMBER:	197607644
ADMINISTRATOR:	LILIAN DE LEON		FACILITY TYPE:	740
ADDRESS:	28009 GOLDEN MEADOW DR.		TELEPHONE:	(310) 357-5239
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY: 6		CENSUS: 4	DATE:	02/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:08 PM
MET WITH:	LIlian De Leon		TIME COMPLETED:	04:08 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	On 02/03/2023 Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA Gibbs was met by Care Staff, Hannah Gitau and the purpose of today’s visit was explained. Later we were joined by Administrator, Lilian De Leon. The facility is licensed to serve 6 elderly 59 years or older residents. Currently the facility has 4 residents, 3 were present during the visit and 1 is in the hospital. Structure The facility is a single-story home in a residential neighborhood. The facility consists of 4 bedrooms, 2 bathrooms, living room, dining room, kitchen, office and garage. Physical Plant LPA and Administrator toured the facility inside and out. The front is landscaped and well maintained. There are two seating areas in the gated front. Under the shaded patio is a table and chairs, and in the yard is an additional table and chairs for residents use. The back is maintained, and the patio has a table and chairs. All walkways were clean, clear and free of obstructions, debris and hazards. There are no bodies of water on the premises. All gates open easily from the inside. Bedrooms LPA and Administrator toured all resident bedrooms. All rooms had the required furniture including bed, nightstand, dresser, chair, and ample closet space. The beds and bedding were in good conditions. All beds had the required bedding including mattress pad, fitted sheets, blankets, comforter, and pillows. All rooms had ample lighting. Bathrooms LPA and Administrator toured all bathroom. Bathroom 1 is a common bathroom for all resident and bathroom 2 is a private bathroom is a resident’s room. Both showers had nonskid mats or material and shower chairs. All security safety bars were securely fastened. Both bathrooms had ample lighting. Water temperature measured between 109.8- through 113.6- degrees Fahrenheit. Bathrooms were found to be within Title 22 regulations and were clean and operational. Linens & Toiletries LPA observed and ample supply of linens, blankets, bath towels and comforters stocked in the hall cupboard and in resident’s closets. LPA observed an ample supply of diapers and chucks for residents. LPA observed an ample supply of personal hygiene stored for residents and additional supply in the garage.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

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 3

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: A GOLDEN HORIZON	FACILITY NUMBER: 197607644
	VISIT DATE: 02/03/2023

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
26
27
28
29
30
31
32

Kitchen LPA and Administrator toured the kitchen. LPA observed all appliances in good working condition. The knobs on the stove top are removed when not in use to ensure the safety of residents (dementia patients turn them on). LPA observed an ample supply cutleries, pots and pans that are in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods and an additional supply in the freezer and refrigerator in the garage. All sharps were locked in a drawer in the kitchen and inaccessible to residents. The water temperature measured at 115.4-degrees Fahrenheit.
Common Rooms LPA toured all common rooms including the living room, dining room and activity room. The living room has ample seating for all residents. There is a fireplace that is covered and inaccessible to residents. In the activity room there is a large table with chairs enough to accommodate all residents. LPA observed games, puzzles, books and activities in a cabinet and bookcase in the activity room. The dining room has a table and chairs to accommodate all residents. All rooms had ample lighting. All walkways were clean, clear and free of obstructions, and hazards. LPA observed the facility to be clean and appropriately furnished at the time of visit.
Toxins All cleaning supplies are locked in a closet in the staff office. Additional supply of cleaning supplies are stored in the garage in locked cabinets. All toxins are inaccessible to residents.
Safety LPA observed a fully charged fire extinguisher mounted to the wall near the front door. Administrator has also just purchased an additional fire extinguisher. All smoke detectors are fully functioning. A carbon monoxide detector is near the kitchen and fully operable. The last emergency drill was conducted on 01/05/23. There is a working landline. LPA observed all the required posting throughout the facility. There are no firearms or ammunition stored on the premises. There are sensors that alert you when the front gate is opened and front door are opened. Residents have a call button in their rooms and when pressed a bell goes off alerting staff they are required.
Infections Control LPA observed the facilities infection control practices. Upon arrival LPA’s temperature was taken, then was screened for Covid 19 and proof of immunization was requested. At the entrance there is a sanitizing station and visitor log. LPA observed infection control signs posted at the entrance of the facility. All staff were observed wearing face masks.
Medications LPA reviewed all resident’s medications and matched them to the MARs. Medications are stored in a locked cabinet in the kitchen and are inaccessible to residents.
Files LPA reviewed all resident files and found they contained the required documentation. LPA reviewed 3 staff files and found they contained the required documentation. LPA did observe that some of the staff CPR has expired.
One deficiency was cited, please see attached 809D. Two technical advisories were cited, please see attached 809TAs.
An exit interview was conducted with administrator and a copy of this report was given.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/13/2023 03:07 PM - It Cannot Be Edited

Created By: Wendy Gibbs On 02/03/2023 at 04:23 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: A GOLDEN HORIZON	FACILITY NUMBER: 197607644
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2023
	Plan of Correction
1 2 3 4	Administror stated she will schedule training right away and send the LPA a copy of the new CPR/First Aid cards to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Eva M Alvarez

LICENSING EVALUATOR NAME:

Wendy Gibbs

LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3