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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320383
Report Date: 11/02/2024
Date Signed: 11/02/2024 04:02:33 PM

Document Has Been Signed on 11/02/2024 04:02 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 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: 3DATE:
11/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:13 AM
MET WITH:Angelique GradneyTIME VISIT/
INSPECTION COMPLETED:
12:24 PM
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On 11/02/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Angelique Grandney. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) ambulatory of which (4) may be non-ambulatory and (1) bedridden elderly resident ages 60 and above. The facility is approved for six (6) hospice waiver. Currently, there is one(1) hospice resident.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: five (5) residents' rooms, three (2) bathrooms, (4) staff rooms (1) staff bathroom, a living area, a dining area, a kitchen, a laundry room, a linen storage, an outside patio area, a garage used for storage. The second floor is mainly used for staff bedrooms.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A water temperature of 106.0 degrees F. A comfortable temperature was maintained in the facility 73 degrees F.

LPA observed the facility is furnished during the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained adequately. The fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) was observed to be maintained in order and accurate.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2024
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 SENIOR ASSISTED LIVING II
FACILITY NUMBER: 198320383
VISIT DATE: 11/02/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms.

An audit of residents #1-#3 (R1-R3) service records and staff #1-#5 (S1-S5) personnel records. The facility is current on CCL annual dues. The facility has a current Administrator Certificate for Angelique Grandney #6005633750 Exp. 05/31/25

During the inspection visit, LPA observed the facility is in the process of renovation of the interior spaces which includes residents bedrooms and common living space areas. New furniture pieces are in boxes and will need to be reassemble. LPA observed old furnishings readily available in stored for purging. LPA observed all (CCL) mandated posters were not posted was due to the makeover process. Due to the renovation in process, a Case Management visit is required to follow up to ensure the facility is operating within Title 22 Regulations.

Technical Violations and Advisory Notes were provided (see LIC 9102)

No Deficiencies cited during this visit.

An exit interview conducted with Angelique Grandney and a copy of the report is provided.


SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC809 (FAS) - (06/04)
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