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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402276
Report Date: 05/18/2024
Date Signed: 05/18/2024 01:47:00 PM

Document Has Been Signed on 05/18/2024 01:47 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GOLDEN HOME CARE CENTERFACILITY NUMBER:
366402276
ADMINISTRATOR/
DIRECTOR:		ISAI, LETITIAFACILITY TYPE:
740
ADDRESS:12839 CYPRESS STREETTELEPHONE:
(909) 570-4237
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 4CENSUS: 2DATE:
05/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Letitia Isai - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Letitia Isai, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (4) non-ambulatory residents, a hospice waiver for (2) and a current census of (2) residents in care. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:
Physical Plant/Environment: Indoor passageways are free of obstruction. Outdoor shaded area is sufficient for resident activities and is enclosed with a self-latching gate. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s showers, toilets, and hand washing areas were operating in sanitary conditions. The hot water temperature in residents' bathrooms measured 120 degrees F. Resident’s bedrooms had beds, bed linen, chairs, night stands, and sufficient lighting. Facility has operating carbon monoxide alarms, laundry equipment and telephone service. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Ombudsman poster, emergency telephone numbers, facility sketch, and facility License. Sharps, disinfectants, and cleaning solutions were kept locked and inaccessible to residents in care. Deficiencies cited: LPA observed resident #1 (R1s) bedroom was not odor free. The Administrator stated that the odor was in the carpet and will have to be replaced. LPA observed in resident #2 (R2s) shredded paper all over resident's bedroom floor. The Administrator stated that the resident shredded a chuck underpad over the floor. LPA observed the backyard swimming pool gate was open and unlocked. The Administrator closed and locked the gate. LPA observed an overgrown Trumpet plant blocking backyard passageway.
Food Service: The facility has sufficient non-perishable and perishable food supply for residents in care. Disinfectants and other cleaning solutions are stored away from food items. Deficiency cited: the facility did not maintain the kitchen counter near the kitchen stove and areas around the microwave clean and clutter free. LPA observed uncovered, leftover food in frying pan and uncovered grease in a bowl in the refrigerator.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GOLDEN HOME CARE CENTER
FACILITY NUMBER: 366402276
VISIT DATE: 05/18/2024
NARRATIVE
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Care & Supervision: Facility has 24-hour, 7 days a week care staff. Facility staff has CPR/first aid training.
Record Review: Resident files reviewed were observed to be complete. Deficiencies cited: Staff #1 (S1) did not have record of training on care supervision with a hospice component and dementia care for review. The Licensee did not maintain record of a current emergency drill conducted with staff for review. The facility did not have record of a complete emergency disaster plan (LIC610E) or similar plan for review.
Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet. The facility has a complete first aid kit. Deficiencies cited: The Licensee did not maintain record of resident #2 (R2s) medications on file for review.

Based on observations and record review, deficiencies are being cited per Title 22, of The California Code of Regulations and Health and Safety Code.

An exit interview was conducted where this report and correction plans were discussed. Copies with Appeal Rights were provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 05/18/2024 01:47 PM - It Cannot Be Edited


Created By: Magda Malcore On 05/18/2024 at 11:35 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
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN HOME CARE CENTER
FACILITY NUMBER: 366402276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by not maintaining resident #1 (R1) bedroom carpet free of odor and not maintaining resident #2 (R2) bedroom floor clean; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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By POC date, the Licensee shall submit to the Licensing Agency documentation of carpet replacement in R1s bedroom and carpet cleaning in R2s bedroom.
Type A
Section Cited
CCR
87307(e)
Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by the backyard swimming pool gate was left opened; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2024
Plan of Correction
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The Administrator closed and locked the gate, no further action required.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 05/18/2024 01:47 PM - It Cannot Be Edited


Created By: Magda Malcore On 05/18/2024 at 11:35 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
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN HOME CARE CENTER
FACILITY NUMBER: 366402276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA observations, the licensee did not comply with the section cited above by storing uncovered food and grease in the refrigerator; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2024
Plan of Correction
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The Administrator shall immediately remove and discard the uncovered food items from the refrigerator.
Type A
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by not maintaining the kitchen counter near the stove and area around the microwave clean and clutter free; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2024
Plan of Correction
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By POC date, the Licensee shall submit to the Licensing Agency documentation of clean and cleared kitchen areas.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 05/18/2024 01:47 PM - It Cannot Be Edited


Created By: Magda Malcore On 05/18/2024 at 11:35 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
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN HOME CARE CENTER
FACILITY NUMBER: 366402276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observations, the licensee did not comply with the section cited above by LPA observed overgrown Trumpet plant blocking backyard passageway; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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By POC date, the Licensee shall submit to the Licensing Agency documentation of cleared passageway.
Section Cited
Personnel Records
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 05/18/2024 01:47 PM - It Cannot Be Edited


Created By: Magda Malcore On 05/18/2024 at 11:35 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
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN HOME CARE CENTER
FACILITY NUMBER: 366402276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by not maintaining documentation of staff #1 (S1s) care supervision with a hospice component training and dementia care training on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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By POC date, The Licensee shall submit to the Licensing Agency documentation of staff training.
Section Cited
Other Provisions
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 05/18/2024 01:47 PM - It Cannot Be Edited


Created By: Magda Malcore On 05/18/2024 at 11:35 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
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN HOME CARE CENTER
FACILITY NUMBER: 366402276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observations, the licensee did not comply with the section cited above by not maintaining a record of resident #2 (R2s) medications for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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3
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By POC date, the Licensee shall submit to the Licensing Agency a record of residents medications.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 05/18/2024 01:47 PM - It Cannot Be Edited


Created By: Magda Malcore On 05/18/2024 at 11:35 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
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN HOME CARE CENTER
FACILITY NUMBER: 366402276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87212(a)
Other Provisions
(a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above by not having a complete emergency disaster plan on file for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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2
3
4
By POC date; the Licensee shall submit to the Licensing Agency documentation of emergency plan.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observations the licensee did not comply with the section cited above by not maintaining record of a current emergency drill conducted with staff for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
1
2
3
4
By POC date, the Licensee shall submit to the Licensing Agency documentation of emergency drill.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024


LIC809 (FAS) - (06/04)
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