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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222267
Report Date: 08/05/2021
Date Signed: 08/05/2021 11:35:45 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOLDEN YEARSFACILITY NUMBER:
191222267
ADMINISTRATOR:MUDER, EVANGELIAFACILITY TYPE:
740
ADDRESS:15822 MAYALL ST.TELEPHONE:
(818) 892-4467
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 0DATE:
08/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Administrator, Evangelia MuderTIME COMPLETED:
11:40 AM
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Licensing Program Analysts (LPAs), Angela Panushkina and Melissa Ruiz conducted an unannounced annual inspection visit at the above facility. Approximately at 9:17am LPA team met with the Administrator, Evangelia Muder, who granted access to home.

Infection control: LPA Panushkina reviewed facility mitigation plan (approved on 01/22/21) to make sure licensee was following current infection control recommendations. Upon arrival the team noticed no COVID-19 signs posted outside the facility, team was not screened by the Administrator and were not asked any infection control questions.

The Administrator informed the LPA(s) that since May 2021 all three residents were relocated to other facilities; due to Administrator having personal health issues. LPA informed the Administrator that since the facility is still licensed, regardless if it's occupied with residents or not, all signs need to be posted at the entrance and they still have to follow all of the infection control procedures. At 9:25am LPA(s) toured the entire facility, and there are currently no residents. Administrator informed LPA(s) there is a possibility she will cease operation.

An exit interview was conducted and copy of this report was given to Evangelia Muder, Administrator.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
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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