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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005848
Report Date: 10/24/2024
Date Signed: 10/24/2024 05:46:14 PM

Document Has Been Signed on 10/24/2024 05:46 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GOLDEN AGE SENIOR HOMESFACILITY NUMBER:
306005848
ADMINISTRATOR/
DIRECTOR:		MICO, RICO G.FACILITY TYPE:
740
ADDRESS:24982 WILKES PLACETELEPHONE:
(562) 338-4099
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 5DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Rico Mico, Virgilio DelantarTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. The Administrator, Rico Mico's Administrator's Certificate expires on March 26, 2026. LPA met with Assistant Administrator, Virgilio Delantar who's Administrator's Certificate expires on 10/18/2025. LPA explained the reason for the visit. LPA observed the facility is a two-story house with 5 resident bedrooms on the first floor, 3 bathrooms, living room, dining room and kitchen. The second floor is one room with a closet. A file review shows the fire clearance and facility sketch which was approved on September 9, 2020 does not have the second floor with the one room and closet. The facility does not have a current valid fire clearance. LPA observed the See Something, Say Something poster (PUB 475) posted in the entry way of the facility. LPA observed all 3 bathrooms are clean and operational. Hot water measured 111.9 degrees Fahrenheit. LPA observed all resident rooms had the required furnishings and bed linens. Smoke detectors and carbon monoxide detectors tested operational. LPA and the Administrator toured the kitchen. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the 5 burner gas stove does not light unassisted. LPA observed food debris on the stove and the top of the stove has grease stains. Administrator Rico Mico arrived during the visit. LPA and the Administrator toured the resident rooms. LPA observed all resident rooms have the required furnishings and bed linens. LPA observed the fireplace in the dining room has a glass door and there is a table placed right in front of the fireplace blocking access. LPA and Administrator toured the backyard. No bodies of water observed. There is a table with an umbrella and chairs to sit outside. LPA observed numerous items stored on the side of the house which has the exit gate. The exit gate is operational. LPA observed, ladders, chairs, bicycles, tools, buckets, walkers, commodes and empty containers stored on the side of the house with the exit gate. There is no record of a current fire drill. LPA reviewed 5 resident files. 5 out of 5 residents did not have a pre-appraisal conducted. 3 out of 5 residents did (Residents 1, 2 and 4) not have a current appraisal/needs and care plan. LPA and the Administrator toured the garage. The garage has a storage which is on the facility sketch. The storage room is used to store furniture. LPA observed a 72 hour emergency food and water supply in the garage.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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 9
Document Has Been Signed on 10/24/2024 05:46 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 10/24/2024 at 04:44 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 AGE SENIOR HOMES
FACILITY NUMBER: 306005848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff members which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee agrees to have staff members 2 and 3 given a health screening. Licensee agrees to submit the completed health screening to the LPA.

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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 10/24/2024 05:46 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 10/24/2024 at 04:44 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 AGE SENIOR HOMES
FACILITY NUMBER: 306005848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, the fire clearance and facility sketch which was approved on September 9, 2020 does not have the second floor with the one room and closet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee agrees to submit a new application (LIC 200) with a new facility sketch showing the second floor with one room and closet, to request a new fire clearance. Licensee agrees to comply with all the requirements issued by the Fire Authority and to notify of any required changes or delays concerning the new fire clearance request. Licensee agrees to comply with the regulation above.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 10/24/2024 05:46 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 10/24/2024 at 04:44 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 AGE SENIOR HOMES
FACILITY NUMBER: 306005848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above, LPA observed the 5 burner gas stove does not light unassisted. LPA observed food debris on the stove and the top of the stove there are grease stains, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Licensee agrees to repair/clean or to replace the stove by the POC due date. Licensee to submit proof of correction to the LPA by the POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff members which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Licensee agrees to have staff trained in compliance with the regulation above and to document all staff training. Licensee to forward proof to LPA by POC due date.
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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 10/24/2024 05:46 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 10/24/2024 at 04:44 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 AGE SENIOR HOMES
FACILITY NUMBER: 306005848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Licensee will complete a pre-appraisal for each resident. LIcensee to submit proof to LPA by the POC due date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Licensee will complete a reappraisal for the 3 residents who did not have a current appraisal, Residents 1, 2 and 4.
Licensee to submit proof of correction to LPA by the POC due date.
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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 10/24/2024 05:46 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 10/24/2024 at 04:44 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 AGE SENIOR HOMES
FACILITY NUMBER: 306005848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on record review, the licensee did not comply with the section cited above, there is no record any emergency drill being conducted, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Licensee agrees to conduct a drill by the POC due date and to conduct drills in compliance with the regulation above and to document all drills. Licensee to provide proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 6 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GOLDEN AGE SENIOR HOMES
FACILITY NUMBER: 306005848
VISIT DATE: 10/24/2024
NARRATIVE
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The garage is used to store extra supplies and is kept locked. LPA reviewed 3 staff files. 2 out of 3 staff did not have a health screening. 2 out of 3 staff members (Staff 2 and Staff 3) did not have the required annual training. All staff are background cleared and associated to the facility. Staff did have CPR training.

Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. A copy of the report along with appeal rights was provided to the Facility Administrator. An exit interview was conducted with Administrator.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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