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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005847
Report Date: 10/15/2024
Date Signed: 10/15/2024 04:34:12 PM

Document Has Been Signed on 10/15/2024 04:34 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:
10/15/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Liza DelaCruz - Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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On 10/15/2024, LPA Mason arrived at the facility for the purpose of conducting a Plan of Corrections inspection. LPA arrived at the facility and was greeted and granted entry by facility staff. LPA met with Administrator (AD) XXXX

On 10/4/2024, LPA issued a citation under the following Title 22 Regulation:

(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.

LPA observed resident medication to be maintained in the packaging received from the pharmacist's office.

Based on today's inspection, LPA determined the facility fulfilled their plan of correction by the assigned POC due date. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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