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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426758
Report Date: 10/09/2023
Date Signed: 10/09/2023 12:41:07 PM

Document Has Been Signed on 10/09/2023 12:41 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 VILLAGEFACILITY NUMBER:
366426758
ADMINISTRATOR:LABAYOG, MARGIEFACILITY TYPE:
740
ADDRESS:11555 RICHMONT RD.TELEPHONE:
(909) 796-0014
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 6CENSUS: 6DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Margie Labayog, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced required annual inspection to the facility. LPA met with Margie Labayog, Administrator and discussed the purpose of the visit.
The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) with a current census of (6) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:
LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Facility outdoor pool is fenced and locked inaccessible to residents in care. Facility backyard is enclosed by a fence with self-closing gates and covered patio is sufficient for outdoor resident activities.
LPA inspected the kitchen. The refrigerator and two (2) freezers are operating in a healthful manner. Hot water temperature is maintained at 105 degrees F. Facility has sufficient non-perishable and perishable food supply for residents in care. Facility has sufficient cups, plates, and utensils for resident use. LPA observed equipment was not kept clean as kitchen stove was saturated with old grease.
LPA inspected residents bedrooms. Bedrooms are equipped with beds, bed linen, nightstands, chairs, storage space and sufficient lighting.
LPA inspected residents bathrooms. Bathrooms are equipment with grab rails and are fully operational. The hot water temperatures tested between 106 and 108 degrees F.
LPA observed facility has operating carbon monoxide alarms and telephone service.
Facility has posted in a common area Community Care Licensing complaint telephone number, emergency telephone numbers, and evacuation plan.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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 VILLAGE
FACILITY NUMBER: 366426758
VISIT DATE: 10/09/2023
NARRATIVE
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Facility has a complete first aid kit and extra first aid supplies. Facility has sufficient linen, towel, emergency supplies, and personal hygiene products for residents. Sharps, disinfectants, cleaning solutions, and toxins are kept safe in a locked cabinet.
LPA observed client medications are kept in a safe in a locked cabinet. All medications are labeled and administered as prescribed.
LPA reviewed staff files for first aid certifications, fingerprint clearances, health screenings, training, and personnel records, all had the required documentation.
LPA reviewed resident files for admissions agreements, physician's reports, pre-admission assessments, personal rights, and safeguarded resource records.
Admissions agreement and pre-admissions appraisals for resident #1 (R1) were not maintained at the facility for licensing agency review. Resident #2 (R2) last physician's assessment on file was conducted on 11/13/2018.
Deficiencies were cited during today's visit. An exit interview was conducted, where the licensing reports and plan of corrections were discussed and copies of the reports 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: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/09/2023 12:41 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/09/2023 at 11:10 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 VILLAGE
FACILITY NUMBER: 366426758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(29)
General Food Service Requirements
(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

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 kitchen equipment was not kept clean as kitchen stove was saturated with old grease, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2023
Plan of Correction
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Licensee/Administrator shall submit to the Licensing agency proof of stove cleaning by POC date
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/09/2023 12:41 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/09/2023 at 12:01 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: GOLDEN VILLAGE
FACILITY NUMBER: 366426758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA file review, the licensee did not comply with the section cited above by Resident #2 (R2) last physician's assessment on file was conducted on 11/13/2018.which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee/Adminstrator shall submit to the licensing agency proof of annual assessment by POC date.
Type B
Section Cited
CCR
87506(b)(15)
(b) each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admissions Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA file review, the licensee did not comply with the section cited above by Admissions agreement and pre-admissions appraisals for resident #1 (R1) were not maintained at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee/Adminstrator shall submit to the licensing agency proof of documentation by POC date.
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: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
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