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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320446
Report Date: 11/01/2024
Date Signed: 11/01/2024 10:55:55 AM

Document Has Been Signed on 11/01/2024 10:55 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GOLDEN SENIOR ASSISTED LIVING IIIFACILITY NUMBER:
198320446
ADMINISTRATOR/
DIRECTOR:		ASIS, VIRGINIAFACILITY TYPE:
740
ADDRESS:2265 W. 237TH STTELEPHONE:
(310) 600-3999
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 0DATE:
11/01/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:37 AM
MET WITH:President Stephen GradneyTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA), Regina Cloyd, conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An application was submitted to Community Care Licensing Division (CCLD) on 12/26/2023 for initial license for a Residential Care Facility for the Elderly to serve ages 60 years and older. The requested capacity is for six (6) non-ambulatory residents of which one (1) may be bedridden. Bedroom #3 is approved for the bedridden resident.
Structure:
Facility is a four (4) bedroom, two (2) bathrooms, single story house with a detached car garage. The facility is a navy-blue home with a living room, dining room, laundry room (dryer is in the garage), kitchen, and a ramp on one side of the house that wraps around the back. The home has a fireplace in the living room with a metal screen cover, and is inaccessible to residents. Outdoor furniture with an umbrella is in the backyard. Passageways, walkways, driveways, steps and patios are free from obstructions.
Bedrooms Residents:
There are be no more than two residents per bedroom. Bedroom #3 has two beds, two chairs, two night stands, one closet and two lamps in addition to one mounted lighting. Bedroom #2 has two beds, two chairs, one large dresser, one closet and two lamps in addition to one mounted lighting. Bedrooms #1 and #4 are private and have the required furniture. Continue to LIC809-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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
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 III
FACILITY NUMBER: 198320446
VISIT DATE: 11/01/2024
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Bathrooms:
All bathrooms have a working toilet, wash basin, and walk-in shower. Bedroom #3 has a private bathroom.
Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in residents’ closet and in the hallway linen closet.
Emergency Phone Numbers, Exit Plan & Menu:
The facility has an active telephone landline.
The Emergency Disaster Plan with Phone Numbers is posted & readily available for review near the main entryway. Fire extinguisher is located next to the refrigerator and mounted on the wall. A second extinguisher is located in the garage.
Food Service:
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. Food supply adequate stored in refrigerator and cupboards and consists of perishables and non-perishables. Dishwasher in kitchen properly installed and functioning.
Smoke Detectors:
Smoke and carbon monoxide detectors located throughout the house and are operational. Smoke detectors are inter-connected.

Continue LIC809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN SENIOR ASSISTED LIVING III
FACILITY NUMBER: 198320446
VISIT DATE: 11/01/2024
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Appliances:
Stove burners, oven, microwave, washer, and dryer are working. There is one refrigerator in the kitchen and is measured at least 40 degrees Fahrenheit for appropriate food storage. Freezer is at 0 zero degrees Fahrenheit. The residence is equipped with central heating.
Toxins:
Locked/stored.
Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, and gauze and current first aid manual, which are stored in the hallway cabinet. It is available for staff use but inaccessible to residents.
Clients & Staff Files:
Applicant will not be handling cash resources of residents.
Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the residents’’ use, commensurate with the plan of operation.
Pool/Jacuzzi & Pets:
None.
Fire clearance:
Fire Clearance with the following special conditions: rooms approved for non-ambulatory of which room #3 is approved for bedridden, approval of delayed egress/secure perimeter/secure locked perimeter (if applicable) was approved on 09/04/2024. Residents’ bedrooms do not have security bars and outside gate currently has a self-closing latch.
Continue to LIC809-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
Page: 3 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN SENIOR ASSISTED LIVING III
FACILITY NUMBER: 198320446
VISIT DATE: 11/01/2024
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Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

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 Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
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