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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004771
Report Date: 08/16/2021
Date Signed: 08/23/2021 07:15:36 AM

Document Has Been Signed on 08/23/2021 07:15 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GOLDEN FLOWER MANOR, LLCFACILITY NUMBER:
306004771
ADMINISTRATOR:FLORICA GHEORGHEFACILITY TYPE:
740
ADDRESS:2411 E. LA PALMA AVE.TELEPHONE:
(714) 215-4283
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 3DATE:
08/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Florica GheorgheTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit for the purpose of conducting a Required - 1 Year evaluation. LPA was greeted and granted entry into the facility by Administrator Florica Gheorghe and reason for visit was explained.

LPA toured the facility with Administrator Gheorghe. There are 3 Residents in care, of which 1 is receiving Hospice services. LPA observed signs to be posted at front entrance of facility on COVID-19 precautions, as well as a sign in sheet, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate which expired on 08/03/2021. Administrator Gheorghe provided proof of re-certification. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper and paper towels. Restrooms had proper hand washing signs posted. One resident was observed eating breakfast and watching TV in the living room. Other 2 residents were in their room. Facility has operating smoke detectors and audible alarms for each sliding door entrance/exit. Facility has Fire Extinguishers which are fully charged. Facility has ample supply of PPE. Facility has a refrigerator in kitchen and garage with ample food supply. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted, a secured location for resident's medication and files. Facility has 30 days supply of medications for Residents. Residents emergency contact information and Physicians reports are current. Visitor's visit in resident's bedroom.

No deficiencies noted during todays visit. An exit interview was conducted with Administrators and a copy of report and Technical Assistance reports were left at facility.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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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