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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603765
Report Date: 03/10/2025
Date Signed: 03/10/2025 01:19:37 PM

Document Has Been Signed on 03/10/2025 01:19 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:GOLDRUSH RESIDENCEFACILITY NUMBER:
198603765
ADMINISTRATOR/
DIRECTOR:		LOPEZ, LORRAINEFACILITY TYPE:
740
ADDRESS:1452 GOLDRUSH DRIVETELEPHONE:
(626) 890-7634
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 4DATE:
03/10/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:57 AM
MET WITH:Lorraine Lopez, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:28 PM
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Licensing Program Analysts (LPAs) Alberto Lopez and Sakinah Madyun conducted an announced pre-licensing visit and met with Administrator Lorraine Lopez and Megan Hill for the purpose of conducting a Pre-Licensing Inspection / Component III visit. This Pre-Licensing Inspection is due to change of ownership. This is the initial visit.
An application for an Initial License was submitted to the department on 04/05/24 The facility will operate as a Residential Care Facility for the Elderly (RCFE). The facility has a total capacity to serve up to six (6) Residents. Fire clearance approved for six (6) residents who may be non-ambulatory, of which up to one (1) may be bedridden. Fire clearance for bedridden residents may be in Room #1. Hospice Waiver requested for up to six (6) residents in care. Dementia care plan is in place.

The facility is a single-story home: Total of five (5) bedrooms three (3) bathrooms, dining room, one (1) living rooms, backyard with locked attached garage, and a laundry area. The physical plant was toured.

Pre-Licensed Inspection Tool was used.
The following was observed/inspected:

· There is a locked storage area that is centrally located for medication.

· Cleaning supplies are kept separate from food and located in a locked cabinet.

· Facility walls, ceilings, floors, window screens and areas around the facility are clean and in good repair.

· Fire extinguishers and smoke/CO2 detectors operate properly.

· Doors and passageways are free of obstruction.

· There are no pools/bodies of water at the facility.

· Facility does not have firearms on premises.

(continued on 809C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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 2
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: GOLDRUSH RESIDENCE
FACILITY NUMBER: 198603765
VISIT DATE: 03/10/2025
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(continued from 809)

· All Required Postings were observed.

· There is an emergency exiting plan with emergency phone numbers posted.

· Facility has a current Emergency disaster plan maintained at the facility.

· Operating telephone is on the premises and will be available to residents.

· Locked area for Staff and Residents files observed.

· First-aid supplies are maintained and readily available.

· Refrigerator and freezer were observed and are maintained at the correct temperatures.

· Food storage and preparation are clean and appropriate for food preparation.

· Hot water temperature was tested and is within the required range of 105-120 degrees F.

· Plan of Operation / Dementia Care Plan / Infection Control Plan observed

Facility plant cleared on today’s visit. Component III was completed with Applicant Lorraine Lopez and Megan Hill, staff as well.

An exit interview was conducted, and a copy of this report has been furnished to 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: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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