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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607644
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:34:00 PM

Document Has Been Signed on 01/16/2025 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:A GOLDEN HORIZONFACILITY NUMBER:
197607644
ADMINISTRATOR/
DIRECTOR:		LILIAN DE LEONFACILITY TYPE:
740
ADDRESS:28009 GOLDEN MEADOW DR.TELEPHONE:
3103575239
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 4DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:27 AM
MET WITH:Hannah Gitau, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:58 PM
NARRATIVE
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On 01/16/2025, The Department of Social Services, Community Care Licensing Division (CCLD) staff conducted an unannounced annual required visit using the CARE Inspection Tool. CCLD staff met with staff one, Hannah Gitau Caregiver (S1) and CCLD staff explained the purpose of the visit. The facility is licensed to serve (6) residents ages 60 and above. All rooms have fire clearance for bedridden residents. Approved hospice waiver for (6).

This is a single-story home consisting of: four (4) resident bedrooms (Bedrooms #1, #2, #3 are single occupancy with full size beds Bedroom #4 is a shared room), one (1) staff room, two (2) bathrooms, one (1) living room, one (1) kitchen with dining area, outdoor shaded patio located in the back yard area, an attached garage along with washer and dryer located outside the garage. The front yard has adequate shaded area with seating and has an enclosed fence.

CCLD toured the physical plant with Caregiver, S1. There are no bodies of water or obstructions on the premises. A total of four (4) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathroom #1 was measured at 117.1°F and Bathroom #2 was measured at 110.1°F, all water sources in the house were observed to be fully operational, without mold, and within Title 22 regulations. CCLD inspected the smoke detectors and determined they were in operable condition. Carbon monoxide / smoke detector combo was located in the garage, above the entrance to the garage from the staff room, and was not in operational condition. Please see LIC809-D.

Evaluation Report Continues, see LIC 809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: A GOLDEN HORIZON
FACILITY NUMBER: 197607644
VISIT DATE: 01/16/2025
NARRATIVE
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CCLD staff observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharp objects were observed and not accessible to residents. The kitchen was inspected and there is sufficient 2-days perishable and 7-days non-perishable food available, on-site, and the food(s) were properly stored. All fire extinguishers were charged and were operable. A review of (3) residents' service files and (3) Medication Administration Records (MAR) was conducted. All three (3) residents have not visited their physician since the year of 2022 and all three (3) residents have been marked as having "Mild Cognitive Impairment" (MCI). CCLD has requested that all four (4) residents have an updated physician's report from the year of 2025, please see LIC809-D. One error was noted in the MAR for one resident (R1). S1 confirmed the medication (M1) has been provided to R1 three (3) times (3x) per day. R1 confirmed with CCLD that they receive M1 3x per day. CCLD cited this deficiency as a technical violation, please see LIC9102-TV. One resident's (R2) documents were unable to be located, please see LIC809-D. All staff paperwork was not available to be reviewed, please see LIC809-D. CCLD reviewed first-aid kit, and was observed to be fully stocked. .

LPA observed the facility's infection control practices, which has met CCLD requirements. A copy of the liability insurance was not provided, please see LIC809-D.

Four (4) deficiencies have been cited during today's visit, please see LIC809-D.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), CCLD observed four (4) deficiencies during today's visit, please see LIC809-D.



An exit interview was conducted with caregiver, Hannah Gitau (S1). A copy of the appeal rights, this facility evaluation report and four (4) deficiencies were provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/16/2025 02:34 PM - It Cannot Be Edited


Created By: Mario Leon On 01/16/2025 at 01:54 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: A GOLDEN HORIZON
FACILITY NUMBER: 197607644

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on CCLD staff's (record review)], the licensee did not comply with the section cited above in one (1) out of one (1) lack of presence of liability insurance for CCLD's review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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CCLD and licensee have agreed that facility will forward Liability insurance was not available to be reviewed. Facility will forward documentation (video/photo) to CCLD staff via email at MARIO.LEON@DSS.CA.GOV on or before the plan of corrections date.
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on CCLD staff's (observation) the licensee did not comply with the section cited above in not having one (1) out of one (1) carbon monoxide detector which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2025
Plan of Correction
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Carbon monoxide detector/smoke detector combo is located in the garage and has been deemed as inoperable. Facility will install new unit(s) and forward documentation (video/photo) to CCLD staff via email at MARIO.LEON@DSS.CA.GOV on or before the plan of corrections date.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/16/2025 02:34 PM - It Cannot Be Edited


Created By: Mario Leon On 01/16/2025 at 01:54 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: A GOLDEN HORIZON
FACILITY NUMBER: 197607644

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on CCLD's (observation) and (record review), the licensee did not comply with the section cited above in one (1) out of one (1) lack of staffing paperwork which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2025
Plan of Correction
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All twenty-nine (29) associated staff records were not available for review. CCLD and Licensee have agreed that Facility will forward all documentation (video/photo) of three (3) main facility staff records to CCLD staff, via email, at MARIO.LEON@DSS.CA.GOV on or before the plan of corrections date.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on CCLD staff's (observation) and (record review)], the licensee did not comply with the section cited above in four (4) out of four (4) residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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CCLD observed that three (3) out of four (4) residents, one (1) resident file was not located on-site, have been marked as "Mild Cognitive Impairment (MCI)" with the latest date as 2022. Zero (0) residents have been marked as having Dementia.
CCLD and licensee have agreed that facility will forward updated records to CCLD staff, via email, at MARIO.LEON@DSS.CA.GOV on or before the plan of corrections date.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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