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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320027
Report Date: 10/23/2022
Date Signed: 10/25/2022 10:32:25 AM

Document Has Been Signed on 10/25/2022 10:32 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GOLDEN CARE LIVING IVFACILITY NUMBER:
198320027
ADMINISTRATOR:GRADNEY, STEPHENFACILITY TYPE:
740
ADDRESS:27711 HAWTHORNE BLVDTELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 0DATE:
10/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Catherine Espino, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Catherine Espino, Administrator and the purpose of today’s visit was explained.

There are currently (0) residents in the facility. (0) residents are ambulatory, (0) are non-ambulatory, () bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (6) bedrooms, (2) full bathrooms, shaded back yard, front yard, there are 3 ramps along side the perimeter of facility laundry area, shed, and a detached 2 car garage.

LPA and Catherine toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-5 are for residents and contain the mandated furniture. Bedroom 6 staff bedroom. The (2) bathrooms have grab bars and non-skid mats and are clean and operational. No First aid kit or manual (No residents); smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. No resident medications or resident files. No staff files either. No food supply, hot water temperature is (109.6) degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (1) fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN CARE LIVING IV
FACILITY NUMBER: 198320027
VISIT DATE: 10/23/2022
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During the visit, LPA did not observed the facility infection control practices. The facility does not have any residents. LPA observed administrator wearing masks, resident private rooms will be converted to isolation rooms (if needed) no trash cans with lids, no cart for PPE’s, no mitigation plan posted and/or in folder, No fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has No internet & IPAD for residents to use, Emergency contacts updated and posted; PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

Technical Advisory (TA) issued.

1. Mitigation Plan was not posted and/or in binder.

An exit interview conducted with Catherine Espino, Administrator and a hard copy of report provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2022
LIC809 (FAS) - (06/04)
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