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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320383
Report Date: 06/19/2024
Date Signed: 06/21/2024 10:57:11 AM

Document Has Been Signed on 06/21/2024 10:57 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 SENIOR ASSISTED LIVING IIFACILITY NUMBER:
198320383
ADMINISTRATOR/
DIRECTOR:		ESPINO, CHRISTIANFACILITY TYPE:
740
ADDRESS:1644 W 222ND STREETTELEPHONE:
(310) 783-0501
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 4DATE:
06/19/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Dinna Meniola & Angelique GradneyTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 06/19/24 at 10:01, Licensing Program Analyst (LPA) Ernand Dabuet initiated a Collateral visit at this facility. LPA met with caregiver Dinna Meniola. LPA explained the purpose of this visit is to gather information regarding a current complaint about Santa Fe Care Homes Complaint number 11-AS-20240617085500.

The visit consisted of an interview with Dinna Meniola staff #1-#2 (S1-S2) who responsible for care and supervision for resident #1 (R1). Interviews with resident #1-#2 (R1-R2). Details on the interview are documented on LIC 812 crossed reference with Santa Fe Care Home #198205144.

During the visit, LPA requested a copies of (R1's) service records and staff and resident roster for review.

An exit interview was conducted with Angelique Gradney, and a hard copy was provided via email.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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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