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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320027
Report Date: 12/13/2023
Date Signed: 12/13/2023 02:16:53 PM

Document Has Been Signed on 12/13/2023 02:16 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 IVFACILITY NUMBER:
198320027
ADMINISTRATOR:GRADNEY, STEPHENFACILITY TYPE:
740
ADDRESS:27711 HAWTHORNE BLVDTELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 2DATE:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Catherine D. EspinoTIME COMPLETED:
01:00 PM
NARRATIVE
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On 11/09/23, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Catherine D. Espino as the purpose of the visit was explained. The facility is licensed for (6) non-ambulatroy of which (1) may be bedridden and have an approved hospice waiver for (6) ages 60 and over. Facility has a current census of (2). Information on upcoming annual fees was provided. Liability insurance is active.

The facility is a single-story structure located in a residential neighborhood. It consists (6) bedrooms of which 2 bedrooms are for staff, (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. No weapons nor bodies of water on the premises. A supply of perishable and non-perishable food was observed. Emergency Water supply is found in the garage.

Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F..

LPA conducted a records review of 2 staff records, 2 resident records, and 2 medication administration records. Medications were centrally stored and properly locked. The last fire was conducted on 11/03/23, 1 fire extinguisher fully charged, carbon monoxide and smoke detectors observed and are operational. Landline and internet were observed.During today’s visit the discrepancies were observed and documented on 809D.

Exit interview conducted with Administrator Catherine D. Espino, appeals rights explained and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 12/13/2023 02:16 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 12/13/2023 at 11:39 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GOLDEN CARE LIVING IV
FACILITY NUMBER: 198320027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411 ©(1 ) Personnel Requirements - General
All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.

Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.


This requirement is not met as evidenced by: staff #2 has expired CPR.
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above as staff (M.E.) has an expired CPR card which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2023
Plan of Correction
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Administrator will require staff to complete CPR training and submit proof of completion to LPA by POC due date.
Type B
Section Cited
CCR
87465(a)(6)
87465(a)(6) Incidental Medical and Dental Care

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:

When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.


This requirement is not met as evidenced by: Mar has gaps in documentation
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as medication administration records are not being documented properly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2023
Plan of Correction
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Administrator to train staff on medication documentation and will provide proof to LPA by POC due date.
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:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023


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Document Has Been Signed on 12/13/2023 02:16 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 12/13/2023 at 11:45 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GOLDEN CARE LIVING IV
FACILITY NUMBER: 198320027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(1)
87303(a)(1) 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.

Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.


This requirement is not met as evidenced by: Crumbs and trash observed.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as kitchen and dinning room were observed to have crumbs and paper and the floor. Pile of laundry were observed on the floor which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2023
Plan of Correction
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Administrator to conducted inservice with staff about maintaining a clean and safe environment to all residnts in care. Administrator to submit proof to LPA by POC due date.
Type B
Section Cited
CCR
87555(b)(25)
87555(b)(25) General Food Service Requirements
(25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.


This requirement is not met as evidenced by: Detergent left on top of washer
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as toxin were observed not locked and accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2023
Plan of Correction
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Administrator will conduct inservice with staff regarding the safety of toxins and submitt proof to LPA by POC due date.
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:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023


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Document Has Been Signed on 12/13/2023 02:16 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 12/13/2023 at 11:54 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GOLDEN CARE LIVING IV
FACILITY NUMBER: 198320027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(1)
87705(f)(1) care of persons with dementias
(f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).


This requirement is not met as evidenced by: 8 inch silver scissors observed on kitchen counter
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as scissors were lobserved accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2023
Plan of Correction
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Administrator to conduct in service on care for persons with demential and will send proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023


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Document Has Been Signed on 12/13/2023 02:16 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 12/13/2023 at 11:58 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GOLDEN CARE LIVING IV
FACILITY NUMBER: 198320027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)(4)
all individuals subject to a criminal record review pursuant to health and safety code secition 1522 shall prior to working, residing or volunteering in a licensed facility:
requesr a trasfer of a criminal record clearance as specified in section 80019(f) or
request and be approved for a transfer ofa criminal record exemption, as specified in section 80019.1(r), unless , uponrequest for the tranfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, nterview, record review, the licensee did not comply with the section cited above in having a care staff not associated at the facility with pending background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2023
Plan of Correction
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Licensee will ensure all staff working at the facility is associated, as part of POC licensee will ensure staff is not working at the facility until staff is associated and without pending background clearance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023


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Document Has Been Signed on 12/13/2023 02:16 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 12/13/2023 at 12:11 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 IV
FACILITY NUMBER: 198320027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(8)(A-F)
87465 Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:
(A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.
(B) Sterile first aid dressings.
(C) Bandages or roller bandages.
(D) Scissors.
(E) Tweezers.
(F) Thermometers.


This requirement is not met as evidenced by: no first aide observed
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as there is no first aide kit in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2023
Plan of Correction
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Administrator to purchase first aide kit and manual and submit proof to LPA by POC due date.

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:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023


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