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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320568
Report Date: 07/02/2025
Date Signed: 07/02/2025 02:43:48 PM

Document Has Been Signed on 07/02/2025 02:43 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 HARVEST CARE HOME 3FACILITY NUMBER:
198320568
ADMINISTRATOR/
DIRECTOR:		MOORE, CHESTERFACILITY TYPE:
740
ADDRESS:2109 W 156TH STTELEPHONE:
(310) 733-9604
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 6CENSUS: 0DATE:
07/02/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:34 PM
MET WITH:Tracy MooreTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 7/02/25, at 1:00pm, Licensing Program Analyst (LPA) Perry Scott conducted an announced visit to Golden Harvest Care Home 3. LPA was greeted by applicant, Tracy Moore, and Chester Moore, Administrator. LPA explained the purpose of today’s Pre-licensing inspection visit.

An application was submitted to Community Care Licensing Division (CCLD) on 01/22/25 in the initial license application for a Residential Care Facility for the Elderly aged 60 and over. The applicant requested a capacity of six (6) non-ambulatory individuals.

Structure:

The home is a three (3) bedroom, one and ½ (1.5) bathroom, single-story home with an attached garage situated in a residential neighborhood. The home includes a living room, activity room, kitchen, and laundry area. The living area included four (4) recliners, fireplace, and a television. The dining area included a dining table and six (6) chairs, office area, and a television. The kitchen has a refrigerator, stove, toaster oven, coffee maker, and a microwave oven. The rear exterior is fenced throughout with a shaded patio that includes a table and chairs. The front porch has a table with two (2) chairs for the residents to sit. The passageways, walkways, and steps are free from obstructions. The front and back entrances are wheelchair accessible.

Bedrooms for Residents:

The facility has three bedrooms (3) bedrooms approved for two (2) non-ambulatory residents per room. All rooms included twin-size beds, two (2) chairs, two (2) nightstands, and table lamps. All bedrooms are equipped with a ceiling lighting, and a dresser. All rooms had closets for ample storage.

Report Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Perry Scott
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2025
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)
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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 HARVEST CARE HOME 3
FACILITY NUMBER: 198320568
VISIT DATE: 07/02/2025
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Bedrooms for Staff:

There is no bedroom designated for live-in staff.

Bathrooms:

The home has one and 1/2 (1.5) bathrooms. One bathroom has a working toilet, washbasin, shower with grab bars, and non-skid mats. The ½ bath has a washbasin and a working toilet.

Linens & Hygiene Supplies:

Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the hall storage area.

Emergency Phone Numbers, Exit Plan & Menu:

The emergency disaster plan is posted along with the exit plan in the living room. There are two (2) fire extinguishers; one located in the kitchen and the other in the hallway. The facility has a land line telephone located in the kitchen. The applicant has submitted a mitigation plan.

Food Service:

Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked cabinet. Food supply is adequately stored in kitchen cabinets and consists of can and other dry goods. The facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days that were observed.

Smoke Detectors:

Smoke and carbon monoxide detectors throughout the interior space are operable.

Toxins & Kitchen:

All toxins are locked and stored under the kitchen sink.

Stove burners, oven, washer and dryer are working. There is one (1) refrigerator in the kitchen. The refrigerator measured a temperature of at least 45 degrees Fahrenheit for appropriate food storage. The home is equipped with a heater and air conditioning.

Report Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Perry Scott
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
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 HARVEST CARE HOME 3
FACILITY NUMBER: 198320568
VISIT DATE: 07/02/2025
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Water Temperature:

The hot water temperature measured 114.3F degrees.

Medications, First-Aid Kit & Book:

A first aid kit and manual are stored in the medication cabinet, which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, and gauze that is locked and inaccessible to residents. The resident's medications will be stored in the same medication cabinet locked in the living room area and inaccessible.

Resident & Staff Files: Records of staff and residents will be stored in a locked cabinet in the living room.

Reading Material & Games: The facility has board games, books, magazines, and other recreational materials for the resident's use, stored in the activity room.

Pool/Jacuzzi & Pets:

There are no pets, jacuzzi, or pool in the fenced area.

Fire clearance:

A fire clearance inspection was conducted on 02/13/2025 and approved for a capacity of six (6) non-ambulatory residents. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on front and back exits.

Component III:

LPA and the applicant completed the Component III PowerPoint presentation, which gives an overview of what to expect while running a Residential Care Facility for the Elderly.

During the pre-licensing inspection no items were observed which do not comply with applicable laws and regulations; no items require a follow up inspection for verification of correction.

Pre-Licensing is complete, and this facility has no deficiencies.

The department 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.

An exit interview was conducted, and a hard copy of this Facility Evaluation Report has been furnished to the applicant, Tracy Moore, and Chester Moore, Administrator.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Perry Scott
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
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