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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320027
Report Date: 10/08/2024
Date Signed: 10/08/2024 09:32:11 PM

Document Has Been Signed on 10/08/2024 09:32 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/
DIRECTOR:		GRADNEY, STEPHENFACILITY TYPE:
740
ADDRESS:27711 HAWTHORNE BLVDTELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 6DATE:
10/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Cheresa ReyesTIME VISIT/
INSPECTION COMPLETED:
03:59 PM
NARRATIVE
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On 10/08/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a Case Management visit at this facility. LPA met with designated administrator Cheresa Reyes who allowed for the entry in this facility. LPA informed Reyes the purpose of the visit is to conduct a health and safety check.

Investigation revealed the following: LPA conducted a tour of the entire facility. During the inspection, LPA observed the following: (4) resident bedrooms, (2) staff bedroom, (1) bathroom, kitchen, living/activity room, and an outside patio area. LPA observed (6) resident residing at this home requiring assistance with assisted daily living (ADLs) and (2) residents in hospice care. This property address is licensed to Golden Care Living IV #198320027. According to Residential Lease Agreement (dated: 08/17/24), Golden Care Living IV lost control of the property effective 08/16/24. The Residential Lease Agreement contract had Lester Mark Samson, & Charesa May Francisco Reyes under contract effective 08/17/24. Serene Living Care submitted an Application for A Community Care Facility LIC 200 on 08/28/24 to Central Applications Bureau, which is still under consideration.



Based on the Department’s observation and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of “Unlicensed Care is Being Provided" is found to be: "Substantiated".

You are hereby issued a Notice of Operation in Violation of the Law letter. You are to cease operation or submit an application to the CCLD Senior Care Office on or before 10/23/24 or relocate the resident to a licensed assisted living facility. If you fail to: cease operation or relocate the resident a civil penalty will be assessed.

(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 IV
FACILITY NUMBER: 198320027
VISIT DATE: 10/08/2024
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Failure to comply will result in civil penalties of $200 per day until a completed application is submitted, operations cease, or written verification from a licensed mental health professional or residents are relocated.

The operator was given a copy of the “Notice of Operation in Violation of Law" letter.

Deficiency Cited: Health and Safety Code 1569.44.

An exit interview was conducted with Cheresa Reyes, and a copy of the report and appeals rights were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2024 09:32 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/08/2024 at 02:53 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: 10/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2024
Section Cited
HSC
1569.44(a)

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1569.44(a) Unlicensed residential care facility for the elderly; definition; operation without license prohibited; procedure upon discovery (a) A facility shall be deemed to be an "unlicensed residential care facility for the elderly" and "maintained and operated to provide residential care" if it is unlicensed and not exempt from the licensee, and any one of the following conditions is satisfied:
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The unlicensed operator shall either cease operation of the unlicensed facility or operations ceased or submit an application to the licensing agency within 15 calendar days by 10/23/24. Failure to comply will result in civil penalties of $200 per day until a completed application is submitted.
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This requirement is not met as evidence by:
Based on interviews conducted and observation the operator is providing unlicensed care to R1-R6 who require elements of care and supervision. The facility is not licensed by CCLD. This poses a potential Health and safety risk 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: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
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