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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881679
Report Date: 07/24/2025
Date Signed: 07/24/2025 10:30:14 AM

Document Has Been Signed on 07/24/2025 10:30 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GOLDEN TURTLE ASSISTED LIVINGFACILITY NUMBER:
331881679
ADMINISTRATOR/
DIRECTOR:		DAVIS, KOREYFACILITY TYPE:
740
ADDRESS:8285 TRISTAN LANETELEPHONE:
(626) 324-0898
CITY:RIVERSIDESTATE: CAZIP CODE:
92507
CAPACITY: 6CENSUS: 0DATE:
07/24/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Korey Davis, LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 8:30 AM, LPA met with Licensee/Administrator Korey Davis. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 10/01/2024 for a total capacity of five (5) non-ambulatory and one (1) bedridden residents. Fire clearance was granted on 12/21/2024. LPA Delgado observed the following:
Structure:
Facility was a one-story house with three (3) resident bedrooms, three (3) resident bathrooms, living room, dining area, kitchen, and office. There was an attached two (2) car garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each resident bedroom #2, #3 and #4 will accommodate any non-ambulatory resident, Licensee has designated bedroom #2 will accommodate bedridden resident however #3 and #4 can accommodate as well per Fire Clearance. Three (3) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, inadequate lighting, and an operable smoke alarm; additional beside tables needed.
Bathrooms:
The three (3) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:00 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 112 degrees Fahrenheit.
(CONTINUED ON LIC 809C)
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Yolanda Delgado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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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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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GOLDEN TURTLE ASSISTED LIVING
FACILITY NUMBER: 331881679
VISIT DATE: 07/24/2025
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(CONTINUED FROM PAGE 1)

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a wood locked box located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the home. Laundry detergents and cleaning supplies were observed in garage away from residents.
Living/Family room:
There was a living room with seating for all clients and TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway and hygiene supplies stored inside a storage inside the garage of the residence.
Yards/Outside:
Patio table with three (3) chairs were observed in the backyard; additional chairs are needed, umbrella is present for shade. There was a gate on the East side of the property with a self-latching lock. All outdoor pathways were not free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the main hallway. Obudsman poster and Let-Us-No poster observed.
General items:
Two (2) fire extinguishers were charged and located in the kitchen and hallway. Eight (8) dual smoke/carbon monoxide alarms and one (1) carbon monoxide detectors were tested and were observed to be in working order. Client records and staff records will be stored in a locked cabinet in the garage. First Aid kit with required components, First Aid manual not observed and locked area for medication storage was observed in the kitchen. LPA observed a facility phone and it has to be connected to service. Emergency water supply was not observed however the required 72-hour emergency food supply was not discernible from the regular food supply. LPA did not observe no bodies of water and no firearms will be stored at the home. LPA confirmed Component III was completed on July 8, 2025 at Riverside RO.
(CONTINUED ON PAGE 3)
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Yolanda Delgado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
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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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GOLDEN TURTLE ASSISTED LIVING
FACILITY NUMBER: 331881679
VISIT DATE: 07/24/2025
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(CONTINUED FROM PAGE 2)

Pre-Licensing is incomplete and the following corrections to be resolved by 08/07/2025:

fix bedframe for bed in bedroom #4
obtain a separate 72-hour emergency food supply
obtain separate emergency water
obtain bedside table for bedrooms #2, #3, #4
obtain lamp for bedrooms #2, #3, #4
obtain additional emergency lightning
obtain and post visiting policy
obtain PPE supplies
obtain a lock door knob for laundry room
obtain First Aid Manual 11th Edition
obtain a landline number
post non-discrimination notice
remove debris from walkway in the backyard
remove personal items from bedrooms


An exit interview was conducted, and a copy of this report will be emailed and a confirmation receipt will be requested.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Yolanda Delgado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
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