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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006462
Report Date: 12/18/2024
Date Signed: 12/18/2024 04:29:11 PM

Document Has Been Signed on 12/18/2024 04:29 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 SENIOR ASSISTED LIVING IFACILITY NUMBER:
306006462
ADMINISTRATOR/
DIRECTOR:		GRADNEY, STEPHENFACILITY TYPE:
740
ADDRESS:2032 CYPRESS AVETELEPHONE:
(310) 600-3999
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY: 6CENSUS: 0DATE:
12/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Administrator Stephen GradneyTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Jenifer Tirre made an announced pre-licensing visit. LPA identified themselves and discussed the purpose of the visit with Licensee/ Administrator Stephen Gradney. An initial application to operate a Residential Facility Care for the Elderly was submitted to CCL on 08/14/2024.

At 2:05pm LPA Tirre along with Licensee/ Administrator Stephen Gradney and Assistant Administrator Nino Lozada toured the facility and observed the following:
Fire clearance approval was received on 10/24/2024. Structure: Facility is a one story, 11 bedroom (4 private Residents bedrooms, 1 shared Resident bedroom, 3 live in staff rooms, 2 storage rooms and 1 office), 3 bathrooms attached duplex with no garage and a beige exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room areas. Bedrooms Residents: All Residents bedrooms meet Licensing requirements. Bathrooms: All resident bathrooms have a working toilet, wash basin, and showers with non-skid mats in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted on wall. Food Service: Facility has as emergency water supply and canned goods. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguisher is mounted and charged. Facility has 3 extinguishers. Facility has audible alarms on sliding/exit doors. Appliances: Gas Stove, dish washer and refrigerator are operational. Toxins: LPA observed toxins secured in storage area.. Water Temperature: Tested and recorded at 118.0 degrees F. in facility bathrooms. Reading Material Games, and Equipment:
facility has activities coordinator, puzzles and games available. Medications, First-Aid Kit & Book: Facility has first aid kit present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate across front yard. LPA observed shaded outdoor seating.

CONTINUED ON 809C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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 2
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 SENIOR ASSISTED LIVING I
FACILITY NUMBER: 306006462
VISIT DATE: 12/18/2024
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Administrator Certificate was observed on wall expiring 07/25/2026

Licensee to address the following corrections by 1/2/2024
  • Water temperature is out of compliance in Restroom 3. Licensee to adjust water temperature
  • Department postings need to be posted in one central area near entrance
  • Facility sketch needs to be updated and reflect correct correlating rooms
  • Grab bars needed for two restrooms
  • Licensee to replace broken faceplates on electric sockets
  • Licensee to provide perishables
  • Licensee to provide emergency food
  • Audible alarm needed for exit 7
  • First Aid Manual book needed
  • First Aid supply of tweezers and scissors needed
  • Restroom 2 needs sink fixed to drain water faster
  • Outside Crawl space piping needs to be adjusted

At this time the facility is not ready to be licensed. Licensee to contact LPA when corrections are complete.

Component III not conducted during visit due to Licensee/ Administrator currently running other licensed facilities.

An exit interview was conducted with Licensee Gradney and a copy of this report was provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC809 (FAS) - (06/04)
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