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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800119
Report Date: 07/20/2022
Date Signed: 08/10/2022 02:58:01 PM

Document Has Been Signed on 08/10/2022 02:58 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GOLD LIVING HOME CAREFACILITY NUMBER:
331800119
ADMINISTRATOR:CANDIDATO, FLORINAFACILITY TYPE:
740
ADDRESS:10233 BONITA AVENUETELEPHONE:
(951) 689-6471
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 6CENSUS: 6DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Florina Candidato, AdministratorTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 11:50 AM, LPA was met by Care giver Evelyn Eduardo and explained the purpose of the visit. Present in the facility during time of visit were three (3) staff as well as six (6) residents. Administrator Florina Candidato arrived during the inspection. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient signage throughout the facility, insufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings by staff. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, PPE supplies need to be maintained at the facility, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility maintains a plan to monitor resident(s) regularly for any changes in condition and to subsequently notify the resident(s) physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, one (1) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview to review this report was conducted and a copy of this report was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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Document Has Been Signed on 08/10/2022 02:58 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 07/20/2022 at 12:41 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLD LIVING HOME CARE
FACILITY NUMBER: 331800119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2(a)
Additional Personal Rights of Residents in Privately Operated Facilities: a) In addition to the rights listed in Section 87468.1. Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, the licensee did not comply with the section cited above; LPA observed no handsoap in several of the resident's bathroom, insufficient PPE supplies and trash cans with no lids inside bathrooms, the licensee did not ensure COVID-19 Infection Control measures in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2022
Plan of Correction
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The licensee will obtain additional PPE supplies, comply with Infection Control measures, complete Staff training on Infection Control measures to be used at all times. Licensee will self-certify compliance with understanding and complying with Infection Control measures and send by 5pm POC.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022


LIC809 (FAS) - (06/04)
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