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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402276
Report Date: 06/24/2022
Date Signed: 06/24/2022 10:02:36 AM

Document Has Been Signed on 06/24/2022 10:02 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:GOLDEN HOME CARE CENTERFACILITY NUMBER:
366402276
ADMINISTRATOR:ISAI, LETITIAFACILITY TYPE:
740
ADDRESS:12839 CYPRESS STREETTELEPHONE:
(909) 570-4237
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 4CENSUS: 3DATE:
06/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Licensee/Administrator Letitia IsaiTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 06/24/2022 at 08:45 AM unannounced in order to initiate a Case Management visit. LPA Brown met with Administrator/Licensee Letitia Isai and LPA Brown explained the purpose of today's visit.

During the visit last 03/08/2022 at 11:30 AM, LPA Brown requested Licensee/Administrator Isai to lock R1's room door knob and also requested to open R1's room from the outside and LPA Brown observed that LIcensee/Administrator Isai is having difficulty opening R1's room door. LPA Brown observed R1's door knob in disrepair. LPA Brown informed Licensee/Administrator Isai that LPA Brown will be issuing a deficiency as this poses immediate Health, Safety or Personal Rights risks to residents in care. Licensee/Administrator Isai informed LPA Brown that new door knobs will be installed on all resident bedrooms after the visit.

In addition, LPA Brown reviewed facility's incident reports and LPA Brown observed that no incident report was submitted regarding R1's fall or R1's observed scratch or bluish mark on R1's forehead. Also, LPA Brown noticed that the facility's last incident report submitted was 12/21/2020. LPA Brown informed Licensee/Administrator Isai that all incidents at the facility involving residents and staff must be reported to Community Care Licensing Division (CCLD) and LPA Brown will be issuing a deficiency for this item as this poses a potential Health, Safety or Personal Rights risk to residents in care.

Moreover, interview with Staff 2 (S2) last 06/16/2022 at 03:53 PM indicated that no awake staff on duty at the facility to provide night supervision to the residents in care at all times. S2 reported "I worked from 8:00 PM to 8:00 AM. I checked the residents every two (2) or three (3) hours. Then, If everything's ok, I sleep at the sofa."
*** Continuation on LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: GOLDEN HOME CARE CENTER
FACILITY NUMBER: 366402276
VISIT DATE: 06/24/2022
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 LPA Brown reviewed the facility's LIC500 Personnel Report and it indicated S1 works 8:00 AM to 08:00 PM and S2 works 8:00 PM to 08:00 AM. LPA Brown explained to Licensee/Administrator Isai that if they have resident with dementia like R1 in reference to R1's pre-admission appraisal, and physician report (LIC624), it requires awake night supervision at all times. Thus, LPA Brown will be issuing a deficiency for this item as this poses an immediate Health, Safety or Personal Rights risk to clients in care.

An exit interview was conducted where this report (LIC809), LIC809D and Appeal Rights were discussed and provided to Licensee/Administrator Letitia Isai.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/24/2022 10:02 AM - It Cannot Be Edited


Created By: Melody Brown On 06/24/2022 at 09:16 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GOLDEN HOME CARE CENTER
FACILITY NUMBER: 366402276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2022
Section Cited
CCR
87303

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors.
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Licensee stated that they will replace all residents room doorknobs and will submit proof of purchase/installation to LPA Brown by POC due date.
Licensee already replaced all residents room doorknob during the visit, POC cleared.
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Based on observation, interview and record review, the Licensee did not comply with the section cited above by having Resident 1 doorknob in disrepair due to it being difficult to open which poses an immediate Health, Safety or Personal Rights risk to residents in care.
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Type A
06/25/2022
Section Cited
CCR87705(c)(4)(A)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia ...(4) There is an adequate number of direct care staff to support each resident’s ... (A) In addition to requirements specified in Section 87415, Night Supervision, ...
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Licensee stated to have one (1) awake night person, on duty at the facility at all times and submit proof (LIC500) to LPA Brown by POC due date.
Licensee stated to submit Statement of Understanding on CCR 87705(c)(4)(A) to LPA Brown by POC due date.

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Based on observation, interview and record review, the Licensee did not comply with the section cited above by not having at least one (1) night person always awake and on duty at the facility due to R1’s primary which poses an immediate risk to residents 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/24/2022 10:02 AM - It Cannot Be Edited


Created By: Melody Brown On 06/24/2022 at 09:20 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GOLDEN HOME CARE CENTER
FACILITY NUMBER: 366402276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2022
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven ...
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Licensee stated to report all incidents at the facility to CCLD. Also, Licensee will submit Statement of Understanding to 87211 Reporting Requirements (a)(1) to LPA Melody Brown by POC due date.

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Based on observation, interview and record review, the Licensee did not comply by not reporting R1's incident to Community Care Licensing Department (CCLD) which poses a potential risk to resident 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022


LIC809 (FAS) - (06/04)
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