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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320024
Report Date: 08/09/2024
Date Signed: 08/09/2024 02:43:51 PM

Document Has Been Signed on 08/09/2024 02:43 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/
DIRECTOR:		GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:1308 HICKORY AVETELEPHONE:
(310) 787-8369
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 5DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Caregiver - Jeremy Jade Ebilane NebresTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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On 08/09/2024 at around 8:00 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Caregiver Jeremy Jade Ebilane Nebres. LPA explained the purpose of the visit and was accompanied by Caregiver inside and outside the facility during this inspection.

This facility is licensed to serve 6 non-ambulatory adults ages 55 and above, of which 2 may be bedridden.
A total of 5 residents are currently residing in this facility.
The Annual Licensing Fees are current.

The facility is a one-story house located in a residential street. The home consists of 5 resident bedrooms, 1 staff room, 3 bathrooms, 1 living/dining/office/kitchen area, 1 attached garage, and 1 backyard patio area with shaded seating.

Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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 08/09/2024 02:43 PM - It Cannot Be Edited


Created By: Socorro Leandro On 08/09/2024 at 01:55 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 III
FACILITY NUMBER: 198320024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

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 ecord review, the licensee did not comply with the section cited above in having an expired liability insurance which poses a potential health and safety risk to persons in care.
POC Due Date: 08/20/2024
Plan of Correction
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Licensee will renew liability insurance and email proof of correction to Socorro.Leandro@dss.ca.gov.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having mold in bathroom 1, bedroom 2’s drawer in disrepair, kitchen cabinet in disrepair and no shower head in bathroom 3, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2024
Plan of Correction
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Mold in bathroom 1, bedroom 2’s drawer in disrepair, kitchen cabinet in disrepair and no shower head in bathroom 3.
Licensee will fix items listed above and email proof of correction to Socorro.Leandro@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:Socorro Leandro
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/09/2024 02:43 PM - It Cannot Be Edited


Created By: Socorro Leandro On 08/09/2024 at 01:55 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 III
FACILITY NUMBER: 198320024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.319(a)
Regulations
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in having a videoconferencing device dedicated for resident use, which poses a personal rights risk to persons in care.
POC Due Date: 08/20/2024
Plan of Correction
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Licensee will have a videoconferencing device dedicated for resident use in the facility. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.
Type B
Section Cited
CCR
87465(a)(1)
Incidental Medical and Dental Care Services
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

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 observed two empty medication bottles for Resident 5, there was no documentation on file indicating that facility attempted to assist R5 with attaning R5's medication, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2024
Plan of Correction
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Licensee will assist R5 with attaining their medication. Licensee will create a plan to ensure that R5 does not run out of medication. Licensee will email proof of correction to Socorro.Leandro@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:Socorro Leandro
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024


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: 08/09/2024
NARRATIVE
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LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Fire drill was conducted on 06/15/2024. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There is a fire extinguisher in the kitchen area and it was last serviced on 02/19/2024. The facility does not have a videoconferencing device dedicated for resident use. LPA observed liability insurance expired on 06/23/2023. LPA observed: mold in bathroom 1, bedroom 2’s drawer in disrepair, kitchen cabinet in disrepair, no shower head in bathroom 3.

4 out of 4 resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed, 5 out of 5 staff records had required documentation.

5 resident records were reviewed and, 5 out of 5 resident records had required documentation.

Deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. Violations regarding: facility in good repair; videoconferencing device dedicated for client use; liability insurance; Resident 5 medication assistance.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Caregiver.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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