<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366405789
Report Date: 12/14/2021
Date Signed: 12/14/2021 01:09:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/13/2021 and conducted by Evaluator Javier Prieto
COMPLAINT CONTROL NUMBER: 18-AS-20211213093806
FACILITY NAME:GOLDEN GUEST HOMEFACILITY NUMBER:
366405789
ADMINISTRATOR:GALASINAO, ADELAIDAFACILITY TYPE:
740
ADDRESS:25070 DAISY AVENUETELEPHONE:
(909) 796-0882
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 4DATE:
12/14/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Adelaida GalasinaoTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is messy.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding an allegation that the facility is messy. LPA met with licensee Adelaida Galasinao and toured facility. LPA Prieto observed clutter of furniture and other items outside the facility in the front area of the home. MS. Galasinao states that arrangements have been made to remove those items, but have been in the front area for several days.

Based on LPA observations and interviews preponderance of evidence standard has been met to substantiate allegation that the facility is messy. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division & Chapter number) are being cited on the attached LIC 9099D).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20211213093806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN GUEST HOME
FACILITY NUMBER: 366405789
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2021
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
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 regulation was not met as evidenced by;
1
2
3
4
5
6
7
Licensee to remove all debris and clutter of items from the front area of the facility and send proof (photos) of correction to LPA by plan of correction date.
8
9
10
11
12
13
14
Facility had clutter of old furniture and other debris in the front area of the facility.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2