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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603573
Report Date: 05/09/2025
Date Signed: 05/09/2025 12:33:17 PM

Document Has Been Signed on 05/09/2025 12:33 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GOLD MEDAL SENIOR LIVING GARDENSFACILITY NUMBER:
198603573
ADMINISTRATOR/
DIRECTOR:		SANTOS, TONIFACILITY TYPE:
740
ADDRESS:311 NORTH MOUNTAIN AVETELEPHONE:
(714) 488-7542
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 6DATE:
05/09/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:27 AM
MET WITH:Administrator Toni SantosTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a unannounced Case Management Visit-Deficiency on 05/09/2025, stemming from initial complaint investigation (28-AS-2025052102030) visit on 05/09/2025. LPA was greeted by Administrator Toni Santos and explained the purpose of the visit.

Case Management findings:

On 05/09/2025, LPA Ramirez reviewed (R1) resident file and observed six (6) Unusual Incident/Injury Reports (LIC 624) from 02/01/2025 through 03/19/2025. These reports revealed R1 had multiple falls and sustained a small skin tear on their elbow. Per Title 22, Division 6, chapter 8, Article 04. 87211(a)(1)(D)- Reporting Requirements- (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This licensing agency did not receive these reports. Staff interviews revealed staff did not send these reports to licensing. This poses a potential risk to the health, safety, or personal rights of persons in care. LPA Ramirez will issue a deficiency based on this observation and staff interviews.




See 809-C
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2025
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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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOLD MEDAL SENIOR LIVING GARDENS
FACILITY NUMBER: 198603573
VISIT DATE: 05/09/2025
NARRATIVE
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During facility tour, LPA Ramirez observed two (2) unsecured non-portable oxygen tanks in R1’s room. Tanks were observed to not be secured in a stand or secured to the wall. This poses a potential risk to the health, safety, or personal rights of persons in care. Per Title 22, Division 6, Chapter 8, Article 11, 87618(b)(3)(E)- Oxygen Administration- Gas & Liquid- (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. LPA Ramirez will issue a deficiency based on this observation.

Two (2) deficiencies were cited for this visit. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided via email.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2025 12:33 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/09/2025 at 12:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLD MEDAL SENIOR LIVING GARDENS
FACILITY NUMBER: 198603573

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2025
Section Cited
CCR
87211(a)(1)(D)

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, the following: (1) A written report shall be submitted to the licensing agency within seven days of the occurrence of any of the events in (A) through (D). This report shall include resident's name, date, nature of
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Licensee agreed to conduct re-training on this regulation by 05/16/2025 and send proof via email to LPA Ramirez.
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event; findings,treatment, if any.(D) Any incident which threatens the welfare, safety or health of any resident. This requirement was not met: Staff did not send these reports to LPA. This poses a potential risk to the health, safety, or personal rights of persons in care.
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Type B
05/16/2025
Section Cited
CCR87618(b)(3)(E)

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(b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall.
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Licensee agreed to conduct re-training on this regulation by 05/16/2025 and send proof via email to LPA Ramirez. Licensee agreed to contact R1's hospice company to obtain oxygen tank stands by 5/16/25.
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This requirement was not met: 2 oxygen tanks were observed to not be secured to a wall or in a stand. This poses a potential risk to the health, safety, or personal rights of persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tony Vasallo
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
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