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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320024
Report Date: 12/07/2022
Date Signed: 09/05/2023 09:32:33 AM

Document Has Been Signed on 09/05/2023 09:32 AM - 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 IIIFACILITY NUMBER:
198320024
ADMINISTRATOR:GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:1308 HICKORY AVETELEPHONE:
(310) 787-8369
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 4DATE:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:CATHERINE ESPINOTIME COMPLETED:
03:45 PM
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On 12/7/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Montoya called the facility, spoke with Staff Catherine Espino (S1) and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for six (6) non-ambulatory, of which two (2) may be bedridden. Facility Annual Fees are current during today’s visit.

During the visit, LPA toured the facility with Staff. This facility consists of five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, kitchen, living room, dining area, office area, shaded patios (located in the front yard and backyard), and a two car garage. Operable smoke detectors in bedrooms and hallways were observed. One operable carbon monoxide detector located in the hallway by the main entrance door is operable. One fire extinguisher last serviced on 2/23/2022 located near the kitchen. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, and toxins were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available.

There are no pools or bodies of water on the premises. There are no firearms on the premises and other dangerous weapons. Potentially dangerous items are kept inaccessible to residents with dementia. The first aid kit has all required supplies. Toxic chemicals are locked in a cabinet in the kitchen. The facility has a written emergency disaster plan posted in the living room. The facility is maintained at a comfortable temperature.



Report Continued in LIC 809-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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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 CARE LIVING III
FACILITY NUMBER: 198320024
VISIT DATE: 12/07/2022
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LPA observed hot water temperature in the common bathroom measures 110.9 degrees Fahrenheit. There are working lights or lamps in each room at the time of visit. There are grab bars for each toilet and shower in the resident bathrooms. Showers have non-skid mats. The facility conducted a Fire/Safety Drill on 11/20/2022. A working telephone remains available.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for residents, staff and visitors, and sanitizing stations in common areas and restrooms. LPA observed S1 was wearing a face covering, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

No deficiency cited during today's visit.

Exit interview conducted, and a copy of this report was provided to Catherine Espino.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
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