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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609621
Report Date: 02/26/2023
Date Signed: 02/26/2023 03:13:38 PM


Document Has Been Signed on 02/26/2023 03:13 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:GOLDEN ASSISTED LIVINGFACILITY NUMBER:
197609621
ADMINISTRATOR:LOPEZ, MONIQUEFACILITY TYPE:
740
ADDRESS:14060 ASTORIA STTELEPHONE:
(818) 367-1947
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:128CENSUS: 120DATE:
02/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Marilyn Nguyen - Licensee RepresentativeTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced Required 1-year infection control inspection to this facility. LPA initially met with staff Amourfino Cruz who called the licensee and arrived 30 minutes later, LPA explained the purpose of the visit.

At 9:18 AM, with the assistance of staff Marcelo Nogar, LPA conducted a tour of the facility inside and out. The following were observed:

There is one main entrance being utilized at the facility. There are required poster posted at the entrance doors. Screening area is located in the reception area. Sign in log book, hand sanitizer and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

The facility had submitted and approved Mitigation Plan and Infection Control Plan.

Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the entrance door. Hand washing, coughing etiquette, physical distancing and other necessary signage were posted in the bathroom and all over the facility. The facility has a designated visitor's area in the front of the main building. The facility has sufficient stock of PPE in the storage room

The facility consists two (2) storey building and a basement. The facility is fire cleared for 128 ambulatory residents, sixty (60) of which maybe non-ambulatory. Hospice waiver for twenty five (25) residents. The basement has the Kitchen, Cafeteria, Activity room, Laundry Area, Staff break room and Storage rooms. There are sixty four (64) shared bedrooms with own bathroom and eight (8) public bathrooms.

(continued to LIC 809-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2023
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN ASSISTED LIVING
FACILITY NUMBER: 197609621
VISIT DATE: 02/26/2023
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Common Areas: The Recreation rooms had chairs that were six (6) feet apart to promote social distancing. LPA observed four (4) signs posted alerting residents to wear masks maintain and two (2) signs for social distancing. The facility has two (2) elevators, both of which are working properly and had signs for masking requirements, coughing etiquette, and social distancing. There is a sign just outside of the elevator that only two (2) individuals should ride at a time. Signs were posted throughout hallways on all floors for social distancing, mask wearing, and cough etiquette.

The facility maintains a comfortable temperature at 75°F. The facility's smoke alarms are hard wired and interconnected and back up and tests are done in house on a regular basis. The facility is equipped with sprinkler system which was last tested on 04/20/22 and valid until 04/30/24. Fire extinguishers are located all throughout the facility and were last serviced on 10/10/22. Fire Drill was last conducted on 1/10/23.



Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings, working signal system, grab bars and nonskid surfaces in the bathrooms. Hot water temperature in random resident bathrooms were checked and measured a range of 108.5°F to 117.1°F. There were enough clean linen available.

Basement: Kitchen and Cafeteria are located in the basement area the kitchen appeared clean, odorless and free from insects. Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable foods. Frozen foods are wrapped and stored appropriately. Kitchen was observed to be inaccessible to residents. The cafeteria has tables which are approximately 6 feet apart from each other and observed to be clean and in proper order. Laundry room was observed to be locked during visit. There were two (2) shaded smoking area in the surrounding backyard equipped with outdoor furniture. There is no body of water in the facility.

At 1:40 PM, LPA reviewed records of six (6) random residents and six (6) staff. Resident and staff records appeared to be complete and updated.

Medications were observed to be locked in the medication room and inaccessible to residents. There were two ( 2) complete first aid kits in the medication room.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2023
LIC809 (FAS) - (06/04)
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