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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320024
Report Date: 10/14/2024
Date Signed: 10/14/2024 04:42:26 PM

Document Has Been Signed on 10/14/2024 04:42 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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: 4DATE:
10/14/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Catherine EspinoTIME VISIT/
INSPECTION COMPLETED:
03:31 PM
NARRATIVE
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On 10/14/24, Licensing Program Analyst (LPAs) Ernand Dabuet and Socorro Leandro conducted a Case Management visit at this facility. LPA met with assistant administrator Catherine Espino and allowed entry inside this facility. LPA informed Espino the purpose of the visit is to conduct a health and safety check in association with complaint #11-AS-20241011142515.

LPAs conducted an audit of resident #2 -#5 (R2-R5) service records (4) out of (4) are unable to self-care require assistance with toileting, and are incontinent. Two (2) out of four (4) are on home health care services. According to staff #2 (S2), (R2-R5) depend on assistance with diaper changes. Espinso verified that the facility Personnel Report LIC 500 (dated: 09/12/24) that three (3) care staff provide care for residents at this facility Monday through Sunday between 7 am - 7 pm.

As a result of the LPAs reviewing (R2-R5’s) service records, home health records, and staff statements, it revealed the facility did not have sufficient personnel staff at all times to provide the service necessary to meet resident needs. The facility does not have a night staff on schedule between 7 pm - 7 am to assist with incontinent services to residents (R2-R5).

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 809-D).

An exit interview conducted with Katherine Espino and a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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 10/14/2024 04:42 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/14/2024 at 02:52 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: GOLDEN CARE LIVING III
FACILITY NUMBER: 198320024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2024
Section Cited
CCR
87411(a)

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Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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Licensee/Administrator have agreed to hire an overnight staff in order to attend to residents' needs while in care. Administrator will send an updated LIC500 to LPA Dabuet, via email, at Ernand.Dabuet@dss.ca.gov
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This has not been met as evidenced by:
Based on record review/interview (R2-R5) are incontinent and requires assistance with diaper changes. Facility did not have a night staff to meet (R2-R5) needs after 7pm. This violation which poses a potential health and safety to residents in care.
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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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024


LIC809 (FAS) - (06/04)
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