<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005847
Report Date: 10/04/2024
Date Signed: 10/04/2024 02:48:56 PM

Document Has Been Signed on 10/04/2024 02:48 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GOLDEN LOVING CARE HOMESFACILITY NUMBER:
306005847
ADMINISTRATOR/
DIRECTOR:		ALVARADO, MARY JEANFACILITY TYPE:
740
ADDRESS:302 S BRODER ST.TELEPHONE:
(562) 388-5088
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 6DATE:
10/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Liza DelaCruz - Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPAs) Dwayne Mason Jr. and William Vanegas arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPAs was greeted at the facility by Liza DelaCruz, Licensee. LPAs explained the purpose of the inspection.

The facility is one-story home with six resident bedrooms, three resident bathrooms, kitchen, dining room, living room, staff room, attached 2-car garage and backyard.Facility appears clean, safe and sanitary. LPAs observed the facility has the necessary postings posted on the walls. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for residents in hallway cabinets. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was serviced on 9/12/2024 according to the attached service tag. Smoke/Carbon Monoxide detector were tested and noted as operational. LPAs observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen and garage. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a cabinet in the kitchen. Exit gates are unlocked. LPA observed exit gates to be unobstructed. LPAs reviewed three resident files and three staff files. LPAs also reviewed medication for three residents. LPA interviewed one staff and one client.



Based on record review, facility does not have documented disaster drills for the last year. A citation is being issued. Based on medication review, a medication error was discovered on 10/3/2024. A citation is being issued. Based on medication review, LPAs determined facility transferred medication between containers. A citation is being issued.

Based on today's inspection, three citations are being issued. An exit interview was conducted and a copy of this report, deficiency pages and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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
Document Has Been Signed on 10/04/2024 02:48 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 10/04/2024 at 02:19 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOLDEN LOVING CARE HOMES
FACILITY NUMBER: 306005847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on medication administration record review, the licensee did not comply with the section cited above in one dosage for one resident which poses an immediate health risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
1
2
3
4
Licensee stated they will conducta Medication Administration training for the facility staff. Licensee stated they wll document the topics covered in the training, all staff that participate in the training and the date, time and location of the training. Licensee stated they will send the previously mentioned documentation to the LPA via email by the assigned POC due date of Monday, October 7, 2024 by 5:00pm Pacific Time.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/04/2024 02:48 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 10/04/2024 at 02:19 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOLDEN LOVING CARE HOMES
FACILITY NUMBER: 306005847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and observation, the licensee did not comply with the section cited above due to resident medication having been transferred between containers which poses a potential health, risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
1
2
3
4
Licensee stated they will conduct a Medication Administration training for the facility staff. Licensee stated they wll document the topics covered in the training, all staff that participate in the training and the date, time and location of the training. Licensee stated they will send the previously mentioned documentation to the LPA via email by the assigned POC due date of Monday, October 7, 2024 by 5:00pm Pacific Time.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to the absence of record drills conducted in the last year. This poses a potential safety risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
1
2
3
4
Licensee stated they will conduct a drill at the facility. Licensee stated they will document the type of drill, date and time of drill and the staff/residents that participate in the drill. Licensee stated they will send the previously mentioned documentation to the LPA via email by the assigned POC due date of 10/11/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4