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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609497
Report Date: 11/06/2023
Date Signed: 11/06/2023 01:55:43 PM


Document Has Been Signed on 11/06/2023 01:55 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:GOLDEN HEART VILLAFACILITY NUMBER:
197609497
ADMINISTRATOR:TAMAYO, SUZETTE M.FACILITY TYPE:
740
ADDRESS:24352 CHERYL KELTON PLTELEPHONE:
(661) 670-8625
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY:6CENSUS: 5DATE:
11/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Carol Agasen & Suzette TamayoTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an annual inspection. LPA knocked on front door, and was greeted by caregiver Carolina Agasen, who informed Administrator Suzette Tamayo, the reason of the visit. The facility is licensed to serve (6) non-ambulatory elderly clients, with (1) hospice waiver. The current census is (5). LPA observed licensing postings, activity calendar, personal and resident rights, grievance and complaint procedures, and disaster and fire plan, and COVID signs posted throughout the facility.

A physical plant inspection was conducted with Administrator. The facility has (4) bedrooms and (2) bathrooms. The common areas, living and dining room, and kitchen area was neat and clean, and passageways were free from obstruction. Inside temperature was comfortable, and residents were observed eating lunch in the dining room. Kitchen cabinets were locked with medication, and knives; cleaning supplies were locked and secured in the garage. Water temperature measured at 106.7. The facility provides an adequate amount of perishable and non-perishable, with an extra refrigerator stored outside in garage. Client’s bedrooms were properly furnished, supplied with appropriate bedding, linens, and were clean. Bathrooms were clean, with soap and towels available, and handicap accessible. Toxic substances were locked and stored in the garage. Smoke alarm and carbon monoxide detectors observed and tested. Fire extinguisher fully charged. All exit doors have alarms. Gates were unlocked and easily to access, with clear passages, and free from obstruction. First aid kit has all required equipment.

Medications are stored in a locked cabinet; centrally stored medication record reviewed, no discrepancies. Staff/client files and training records reviewed; all licensing documents observed in files. All clients and staff are vaccinated, and records were observed. The facility has sufficient stock of PPE in a storage cabinet located in the garage; as well as personal hygiene products available for residents. Exit interview conducted, and copy for report provided.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
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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