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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006529
Report Date: 01/16/2025
Date Signed: 01/16/2025 03:47:19 PM

Document Has Been Signed on 01/16/2025 03:47 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GOLDEN HEARTS ELDERLY CARE 2FACILITY NUMBER:
306006529
ADMINISTRATOR/
DIRECTOR:		ELAHI, NARGISFACILITY TYPE:
740
ADDRESS:25231 ROMERA PLACETELEPHONE:
(949) 716-0016
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 3DATE:
01/16/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:31 PM
MET WITH:Nargis Elahi, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit in conjuction with complaint control number 22-AS-20250110122555.

During the visit, LPA Mendivil discussed reporting requirements as on the visit on 12/30/2024 LPA Mendivil observed Resident 1 (R1) on the floor of the living room. Administrator//Licensee Nargis Elahi stated she did not report the fall that occurred on 12/30/2024 because it did not result in injury of the resident.

LPA Mendivil reviewed reporting requirements with Administrator/Licensee Nargis.

LPA Mendivil requested document of LIC 602 Physician's Report for R1, Administrator/Licensee Nargis stated did not have a copy of LIC 602 at present time. LPA Mendivil reviewed resident records regulation with Administrator/Licensee.

Based on observations made during today's visit deficiencies are being cited. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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 2
Document Has Been Signed on 01/16/2025 03:47 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 01/16/2025 at 11:28 AM
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 HEARTS ELDERLY CARE 2
FACILITY NUMBER: 306006529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2025
Section Cited
CCR
87211(1)(D)

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(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...
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Licensee/Administrator agreed to submit LIC 624 for incident that occured on 12/30/2024. LIcensee agreed to review reporting requirement regulation and provide proof of understanding.
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(D) Any incident which threatens the welfare, safety or health of any resident.. This requirement was not met as evidence by Administrator not reporting a fall that occurred on 12/30/2024. This poses a potential health and safety risks to persons in care.
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Type B
01/22/2025
Section Cited
CCR87506(d)

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(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. :
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Licensee/Administrator agreed to email LPA LIC 602 by POC due date
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This requirement was not met as evidence by facility was unable to provide LPA Mendivil with requested documents for Resident 1 (R1). This poses a potential health & safety risk to person in care,
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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