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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320024
Report Date: 09/07/2023
Date Signed: 09/07/2023 12:42:32 PM

Document Has Been Signed on 09/07/2023 12:42 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, 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: 5DATE:
09/07/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Reynaldo FrancoTIME COMPLETED:
12:45 PM
NARRATIVE
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On 09/07/2023 at 8:53 AM, Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Continuation Inspection and met with Reynaldo Franco and Maria Lilibeth Franco, Caregivers. Five (5) residents and two (2) staff were present during this inspection.

Facility is licensed to serve six (6) non-ambulatory residents, two (2) may be bedridden in any room. The facility also has an approved hospice waiver for six (6) residents and two (2) residents are currently on hospice. The facility currently has 4 non-ambulatory residents and 1 ambulatory. The Annual Licensing Fees are current.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 110.8 and 112.2 in the kitchen, Room 1 and 2. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN CARE LIVING III
FACILITY NUMBER: 198320024
VISIT DATE: 09/07/2023
NARRATIVE
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Two (2) staff records were reviewed, two (2) resident records were reviewed.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and left with Reynaldo Franco.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/07/2023 12:42 PM - It Cannot Be Edited


Created By: Regina Cloyd On 09/07/2023 at 11:49 AM
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 III
FACILITY NUMBER: 198320024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, LPA did not observe Health Screening Reports (LIC 503) for Staff S2, S3, S5, S6, and S7, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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The administrator will obtain Health Screening Reports (LIC 503) for Staff S2, S3, S5, S6, and S7. Proof of correction will be submitted via email to regina.cloyd@dss.ca.gov

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:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


LIC809 (FAS) - (06/04)
Page: 3 of 15
Document Has Been Signed on 09/07/2023 12:42 PM - It Cannot Be Edited


Created By: Regina Cloyd On 09/07/2023 at 11:49 AM
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 III
FACILITY NUMBER: 198320024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, LPA did not observe a needs and service plan for residents 2 and 5, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Adminstrator will complete needs and service plan for residents 2 and 5 and submit proof of correction to regina.cloyd@dss.ca.gov
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on recird review, the licensee did not comply with the section cited above, LPA did not observe a physician's report for resident 4, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Administrator will retrieve a physician's report for resident 4 and email proof of correction to regina.cloyd@dss.ca.gov
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:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


LIC809 (FAS) - (06/04)
Page: 4 of 15
Document Has Been Signed on 09/07/2023 12:42 PM - It Cannot Be Edited


Created By: Regina Cloyd On 09/07/2023 at 11:49 AM
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 III
FACILITY NUMBER: 198320024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, LPA did not observe results of TB examination for R2, R3, and R5, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Administrator will obtain TB examination for R2, R3, and R5 and email proof of correction to regina.cloyd@dss.ca.gov
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, LPA was unable to review onsite fire drills, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Administrator will conduct quarterly fire drills, maintain record on site, and email proof of correction to regina.cloyd@dss.ca.gov
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:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


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