197609621-1-13-2024-31-AS-JGTN-CZG2JC-20240113162607

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609621
Report Date: 01/13/2024
Date Signed: 01/13/2024 04:26:22 PM

Document Has Been Signed on 01/13/2024 04:26 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 ASSISTED LIVING		FACILITY NUMBER:	197609621
ADMINISTRATOR:	LOPEZ, MONIQUE		FACILITY TYPE:	740
ADDRESS:	14060 ASTORIA ST		TELEPHONE:	(818) 367-1947
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY:	128	CENSUS: 115	DATE:	01/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Amourfino Cruz - Staff		TIME COMPLETED:	03:35 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) 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 forty five (45) minutes later, LPA explained the purpose of the visit. At 9:35 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. 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. There were two (2) shaded smoking area in the surrounding backyard equipped with outdoor furniture. There is no body of water in the facility. (continued to LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN ASSISTED LIVING	FACILITY NUMBER: 197609621
	VISIT DATE: 01/13/2024

NARRATIVE

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(continued from LIC 809)

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.

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 10/13/23. Fire Drill was last conducted on 10/09/23

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 112.5°F to 118.9°F. There were enough clean linen available. There is no evacuation chair at both stairwell of the facility.

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. Laundry room is located in the basement and was observed to be locked during visit.

At 1:25 PM, LPA reviewed records of ten (10) 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.

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/13/2024 04:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ASSISTED LIVING	FACILITY NUMBER: 197609621
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(f)(1)

Other Provisions

(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above by not having the evacuation in their stairwell, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/23/2024
	Plan of Correction
1 2 3 4	The licensee agreed to purchase the evacuation for each stairwell at the facility and will submit the proof of purchase to CCL on or before the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

LIC809 (FAS) - (06/04)

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