Golden Senior Assisted Living III

Type of visit: Required - 1 Year

On 10/28/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff. Administrator Brenda Hernandez joined us later. The facility is licensed to serve six (6) non-ambulatory residents age range 60 and over, all of which one (1) may be bedridden. Bedridden is to reside in bedroom #3. The facility has a hospice waiver approved for six (6). The facility is a single-story house located in a residential neighborhood and consists of four (4) bedrooms, two (2) bathrooms, living room, dining room, kitchen, a shaded patio and a garage. The facility is clean, sanitary, and in good repair. Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Continue to LIC809-C. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured at 108.9 degree Fahrenheit. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Doorways were free of obstructions. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and tonics were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced September 19, 2025 was observed in the kitchen area. Staff tested the carbon monoxide detector and smoke detectors in the house. Devices were functional and interconnected. Five staff records were reviewed, five out of five staff records had current first aid certificates and required criminal record clearances or criminal record exemptions. Two staff interviews were conducted. Five resident records were reviewed and, five out of five resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed. No deficiencies are being cited. An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Administrator Brenda Hernandez.the state’s words, verbatim · CDSS document, Oct 28, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA), Regina Cloyd, conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An application was submitted to Community Care Licensing Division (CCLD) on 12/26/2023 for initial license for a Residential Care Facility for the Elderly to serve ages 60 years and older. The requested capacity is for six (6) non-ambulatory residents of which one (1) may be bedridden. Bedroom #3 is approved for the bedridden resident. Structure: Facility is a four (4) bedroom, two (2) bathrooms, single story house with a detached car garage. The facility is a navy-blue home with a living room, dining room, laundry room (dryer is in the garage), kitchen, and a ramp on one side of the house that wraps around the back. The home has a fireplace in the living room with a metal screen cover, and is inaccessible to residents. Outdoor furniture with an umbrella is in the backyard. Passageways, walkways, driveways, steps and patios are free from obstructions. Bedrooms Residents: There are be no more than two residents per bedroom. Bedroom #3 has two beds, two chairs, two night stands, one closet and two lamps in addition to one mounted lighting. Bedroom #2 has two beds, two chairs, one large dresser, one closet and two lamps in addition to one mounted lighting. Bedrooms #1 and #4 are private and have the required furniture. Continue to LIC809-C. Bathrooms: All bathrooms have a working toilet, wash basin, and walk-in shower. Bedroom #3 has a private bathroom. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in residents’ closet and in the hallway linen closet. Emergency Phone Numbers, Exit Plan & Menu: The facility has an active telephone landline. The Emergency Disaster Plan with Phone Numbers is posted & readily available for review near the main entryway. Fire extinguisher is located next to the refrigerator and mounted on the wall. A second extinguisher is located in the garage. Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer next to the sink. Food supply adequate stored in refrigerator and cupboards and consists of perishables and non-perishables. Dishwasher in kitchen properly installed and functioning. Smoke Detectors: Smoke and carbon monoxide detectors located throughout the house and are operational. Smoke detectors are inter-connected. Continue LIC809-C Appliances: Stove burners, oven, microwave, washer, and dryer are working. There is one refrigerator in the kitchen and is measured at least 40 degrees Fahrenheit for appropriate food storage. Freezer is at 0 zero degrees Fahrenheit. The residence is equipped with central heating. Toxins: Locked/stored. Medications, First-Aid Kit & Book: A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, and gauze and current first aid manual, which are stored in the hallway cabinet. It is available for staff use but inaccessible to residents. Clients & Staff Files: Applicant will not be handling cash resources of residents. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the residents’’ use, commensurate with the plan of operation. Pool/Jacuzzi & Pets: None. Fire clearance: Fire Clearance with the following special conditions: rooms approved for non-ambulatory of which room #3 is approved for bedridden, approval of delayed egress/secure perimeter/secure locked perimeter (if applicable) was approved on 09/04/2024. Residents’ bedrooms do not have security bars and outside gate currently has a self-closing latch. Continue to LIC809-C. Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance. An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Nov 1, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Interview Method: Telephone interview On 9/13/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Sep 13, 2024