198320383-10-13-2023-11-AS-RCLD-CWKU9P-20231013152329

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320383
Report Date: 10/06/2023
Date Signed: 10/13/2023 03:23:42 PM

Document Has Been Signed on 10/13/2023 03:23 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	GOLDEN SENIOR ASSISTED LIVING II		FACILITY NUMBER:	198320383
ADMINISTRATOR:	ESPINO, CHRISTIAN		FACILITY TYPE:	740
ADDRESS:	1644 W 222ND STREET		TELEPHONE:	(310) 783-0501
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 6		CENSUS: 4	DATE:	10/06/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Christian Espino		TIME COMPLETED:	12:45 PM

NARRATIVE

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On 10/06/2023 8:53 AM, the Licensing Program Analyst (LPA), Regina Cloyd, conducted an announced visit to the facility for purpose of a pre-licensing evaluation. Today’s pre-licensing evaluation was conducted with Christian Espino, Administrator.

An application was submitted to CCLD on 08/10/2023, for a Change of Ownership (CHOW) for a Residential Care Facility for the Elderly to serve residents who are 60 years and older. The requested capacity is for six, (5) five non-ambulatory and (1) one bedridden. Fire clearance approved on 08/02/2023.

Facility is a two-story house with (8) eight bedrooms (Bedrooms 1-5 are for residents and Bedrooms 6-8 are upstairs staff rooms), (3) three bathrooms (two downstairs for residents and one upstairs for staff), (1) one dining area/family room, (1) one kitchen, laundry room, backyard, stairs, and 2-car garage. Bedroom Five is designated as a shared (bedridden and non-ambulatory) room. The private bedrooms are spacious and will easily accommodate the client's furnishings.

All bathrooms have a working toilet, wash basin, and shower. There are two bathrooms that will accommodate non-ambulatory residents in a wheel chair.

Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen in storage room.

Fire extinguisher located near the kitchen was serviced 02/10/2023.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN SENIOR ASSISTED LIVING II	FACILITY NUMBER: 198320383
	VISIT DATE: 10/06/2023

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Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer next to the sink. A 7-day supply of non-perishable and 2-day supply of perishable was on site. Refrigerator is in good repair and meet the required temperatures. Toxins are locked under the sink.

Laundry room with detergent and cleaning supplies are in a locked room. Water temperature tested at 112F in one shower at the rear of the house and 113F at the bathroom sink near the kitchen.

Battery operated smoke and carbon monoxide detectors are operational. A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and first aid manual, which are stored in the medicine cabinet, available for staff use but inaccessible to residents.

Applicant will not be handling cash resources of residents.

The facility has board games, books, and other recreational materials for the residents' use.

Prelicensing:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance. During the prelicensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected and proof of correction shall be submitted to the CCLD office via email to regina.cloyd@dss.ca.gov by 10/23/2023. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. During facility tour and interview, LPA did not observe a posting of the facility's policy regarding theft and investigative procedures.
2. During facility tour, LPA did not observe a second set of furniture in the shared bedrooms.
3. During facility tour and interview, LPA did not observe sufficient night lights in the hallways and passages to nonprivate bathrooms.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN SENIOR ASSISTED LIVING II	FACILITY NUMBER: 198320383
	VISIT DATE: 10/06/2023

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4. During record review and interview, LPA did not observe a plan of operation that address the needs of residents with dementia.
5. During record review and interview, LPA did not observe the facility's plan of operation that includes a statement of how the facility intends to meet the overall health, safety, and care needs of bedridden persons.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

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