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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603946
Report Date: 02/26/2026
Date Signed: 02/26/2026 01:55:04 PM

Document Has Been Signed on 02/26/2026 01:55 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GOLDEN HORIZON RESIDENCEFACILITY NUMBER:
198603946
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, GERALDINE BFACILITY TYPE:
740
ADDRESS:163 N PASADENA AVENUETELEPHONE:
(626) 804-3399
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 6CENSUS: 6DATE:
02/26/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Geraldine Rodriguez CEO/ AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analysts (LPA) Nune Margaryan conducted an announced pre-licensing visit using CARE Tool. LPA met with Administrator Geraldine Rodriguez and explained the reason for the visit. This Pre-Licensing Inspection is due to a change of ownership. The facility has an approved fire clearance for four (4) non-ambulatory residents, one (1) ambulatory and one (1) bedridden resident. Facility approved for total capacity of (6) six.

The facility is a single-story home, located in a residential area, that consists of a living area, dining area, four (4) resident bedrooms, two (2) bathrooms (1 for staff and 1 for residents), a kitchen, detached garage/ storage room. LPA toured the facility. All indoor and outdoor passageways were free of obstruction. The front and backyard are well maintained and there are no pools or large bodies of water. All rooms were properly furnished with appropriate beddings and linens with sufficient lighting. The hot water temperature was tested and measured within Title 22 Regulation guidelines. Grab bar and non-slip mat was observed in the bathroom bathing area. Common areas including the living room and dining area were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Facility wall thermostat was set at 75.0°F and observed to be within the required range. Laundry located in the garage. There is second refrigerator in the garage. Garage/Storage door is locked. LPA observed shaded seating area in the front of the house. Carbon monoxide detectors are present at the facility and residents bedrooms. They were tested and were operational during the visit. The kitchen was inspected. There is sufficient dishes and utensils in the kitchen.

Continue 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2026
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN HORIZON RESIDENCE
FACILITY NUMBER: 198603946
VISIT DATE: 02/26/2026
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There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked and are inaccessible to residents. LPA observed plenty of linens and towels in the linen closet in the dining room. Fire extinguisher observed in the facility fully charged. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. Resident and staff records locked in a cabinet located in the dining room area. The common area is properly furnished, and activity supplies are available. The dining room is near the kitchen and has sufficient seating.

LPA conducted Component III with Administrator. The Pre-licensing is complete, and the facility has no deficiencies.

Exit interview conducted and a copy of this report was provided to Administrator. 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.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2026
LIC809 (FAS) - (06/04)
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