<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320027
Report Date: 06/27/2025
Date Signed: 06/27/2025 11:52:36 AM

Document Has Been Signed on 06/27/2025 11:52 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
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:
3109891941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 5DATE:
06/27/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:34 AM
MET WITH:Kathleen Mantes - CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/27/25 Licensing Program Analyst (LPA) Mario Leon conducted a case management, with primary focus on physical plant and medication management. LPA was met by staff two, Kathleen Mantes - Caregiver (S2), later by staff one, Cheresa Reyes - Caregiver (S1) and LPA explained the purpose of today’s visit. During today's tour, LPA observed three (3) staff present, for a ratio of 1:1.67 (one (1) staff to one point six-seven (1.67) resident(s)). The facility is licensed to operate for six (6), non-ambulatory, elderly adults ages 60 and above of which (1) may be bedridden, The facility is approved for six (6) hospice residents. Currently, the facility has five (5) residents in care. One (1) resident is currently receiving hospice services.
The facility is a one-story house, located in a residential neighborhood, which consists of the following : four (4) resident bedrooms, two (2) staff bedrooms, two (2) bathrooms, a kitchen, a dining room, a living room, an activity room and an outside, tree-shaded, back yard and patio.
LPA observed the facility to be fully furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and two-days of perishable and seven-days of non-perishable food was maintained adequately. An additional freezer is located in the back yard with additional frozen food items. Fire extinguishers are fully charged. The facility has last conducted emergency fire drill on 06/02/25. A review of the Medication Administration Record (MAR) of residents one (1) through five (5) (R1-R5) was observed and all entries have been entered correctly. From 10:00AM - 10:15AM LPA held an interview with resident five (R5). R5 has confirmed that staff are providing appropriate medication management.
LPA observed First Aid Kit was maintained. A land-line phone was observed and tested, marked as operational. LPA observed smoke detectors in bedrooms and common areas, and a carbon monoxide detector located in the kitchen. LPA requested all detectors them to be tested and LPA verified all are in operational condition. The facility has current liability insurance on file, effective through 08/19/25. During the visit, LPA observed the facility's infection control practices and LPA observed screening protocols for visitors, staff,... Report continues, see LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
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: 06/27/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
and residents, and sanitizing stations in common areas and restrooms and all mandated inspection control posters were posted.

During today's tour, according to Title 22 regulations, LPA observed one (1) deficiency as follows: Screen, located in room #3, in disrepair. LPA also observed debris located in two (2) backyard exit doorsills and also in doorsill of room #3. Additionally, windowsills and screens have been observed as dirty, needing to be cleaned. Please see LIC809-D.

An exit interview was held with staff one, Cheresa Reyes - Administrator designee (S1), and a copy of the facilities' appeal rights, deficiencies cited and this report have been provided.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/27/2025 11:52 AM - It Cannot Be Edited


Created By: Mario Leon On 06/27/2025 at 11:32 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: 06/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2025
Section Cited
CCR
87303(c)

1
2
3
4
5
6
7
87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair.
This has not been met as evidenced by:
based on LPA's observations; the screen, located in room #3, in disrepair.
1
2
3
4
5
6
7
Licensee and LPA have agreed that the facility will make sure to clean window/doorsills as well as screening throughout the facility. Licensee will provide video/photo evidence of the area(s) in question to LPA at Mario.Leon@DSS,CA.GOV on or prior to POC due date, 06/30/25.
8
9
10
11
12
13
14
LPA also observed debris located in two (2) backyard exit doorsills and also in doorsill of room #3, which may pose a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Mario Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4