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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005848
Report Date: 09/30/2025
Date Signed: 10/01/2025 10:22:06 AM

Document Has Been Signed on 10/01/2025 10:22 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
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:
09/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Rico MicoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by staff and LPA explained the nature of the visit. LPA met with Rico Mico, Administrator and explained the nature if the visit. There are five residents at the facility and there are two residents receiving hospice services currently.

LPA accompanied by Administrator began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage located in the garage in a freezer and a spare refrigerator. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage closet located in the bedroom hallway. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. Medication cross checked for accuracy of date and dosage. LPA inspected the bathrooms, and LPA measured the hot water temperature which measured 107.9 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and locked in the garage. The facility has an available clean supply of linens in the hallway storage and a

Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Ruth Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2025
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
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GOLDEN AGE SENIOR HOMES
FACILITY NUMBER: 306005848
VISIT DATE: 09/30/2025
NARRATIVE
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storage closet by resident bedroom. LPA inspected residents’ bedrooms which has sufficient lighting to ensure safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Carbon monoxide and smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there is several shaded seating areas for residents’ enjoyment. LPA observed a fire extinguisher with service date of November 1, 2023, mounted in the kitchen wall. LPA reviewed and verified fire drill logs. Facility has a second floor which is inaccessible to residents in care, door that leads to the second floor is in the garage. There are no residents residing on the second floor of the facility. LPA verified resident in care do not have access to the second floor. LPA began reviewing records. LPA reviewed five resident records. LPA reviewed three employee records. All employees present have a criminal record clearance and are associated with the facility. LPA observed records reviewed have a current First Aid certificate.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for deficiencies.

This report was reviewed with the Administrator and a copy of this report LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Ruth Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/01/2025 10:22 AM - It Cannot Be Edited


Created By: Ruth Martinez On 09/30/2025 at 12:32 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: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)

87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information.
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 facility resident records were observed to have incomplete records by being blank, no signature, missing, or incomplete forms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2025
Plan of Correction
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Licensee to ensure all records are completed by POC due date. License to notify LPA when records are complete.
Type B
Section Cited
CCR
87203
87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic

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 in which licensee failed to ensure that the fire extinguisher was appropriately charged yearly poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2025
Plan of Correction
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Licensee stated that they will purchase a new fire extinguisher. Licensee to send proof of purchase by sending a picture of the receipt to LPA by email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Ruth Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
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