197609497-12-27-2021-31-AS-ADUA-CA4TCH-20211227133646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609497
Report Date: 12/27/2021
Date Signed: 12/27/2021 01:37:57 PM

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 HEART VILLA		FACILITY NUMBER:	197609497
ADMINISTRATOR:	TAMAYO, SUZETTE M.		FACILITY TYPE:	740
ADDRESS:	24352 CHERYL KELTON PL		TELEPHONE:	(661) 670-8625
CITY:	NEWHALL	STATE: CA	ZIP CODE:	91321
CAPACITY:	6	CENSUS: 5	DATE:	12/27/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Suzette Tamayo		TIME COMPLETED:	01:26 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Abeye Duguma met with the Suzette Tamayo for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 11:30am and the following was noted: There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in the backyard. The facility has sufficient stock of PPE in a storage cabinet located in the garage. The facility has a total of five (05) bedrooms for residents and two (02) bathrooms for both residents and staff. The facility is fire cleared for six (06) non-ambulatory and a hospice waiver for two (02). The facility is currently occupying five (05) non-ambulatory residents of which three (03) are under hospice care. The facility has outdoor furniture, with a covered shaded area for residents. The facility does not have a swimming pool/body of water. The garage is being used for laundry and storage. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the garage. Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN HEART VILLA	FACILITY NUMBER: 197609497
	VISIT DATE: 12/27/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Knives and sharps are observed to be locked in a drawer inaccessible to residents. Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 70°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located in the kitchen, observed to be full and last inspected on 03/15/2021. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 108.6°F. Towels and washcloths are not shared. There was enough clean linen available in the storage closet and in each residents room. LPA observed medication to be locked and inaccessible to residents, located in the kitchen. There is a complete first aid kit located in the hallway cabinet.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2