197609631-9-15-2022-31-AS-TCAS-CJAPFY-20220915111731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609631
Report Date: 09/15/2022
Date Signed: 09/15/2022 11:18:47 AM

Document Has Been Signed on 09/15/2022 11:18 AM - 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 HILLS RETIREMENT CTR INC		FACILITY NUMBER:	197609631
ADMINISTRATOR:	GUEVARA, ITZEL		FACILITY TYPE:	740
ADDRESS:	10159 HILLHAVEN AVE		TELEPHONE:	(818) 352-1559
CITY:	TUJUNGA	STATE: CA	ZIP CODE:	91042
CAPACITY:	60	CENSUS: 36	DATE:	09/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Adriana Cisneros		TIME COMPLETED:	11:15 AM

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced infection control inspection/visit. Upon arriving, LPA was greeted by the front desk receptionist Emily Shah. Facility has a health screening questionnaire and masks for visitors. There have not been any active or past COVID cases at the facility, and 99.% of residents and all staff have been vaccinated. The current census is (36). LPA observed staff and residents to have full mask covering; it not recommended but not required. COVID-19, CDC, Department of Public Health, and Licensing postings and hand sanitizing stations were visible seen at each corner of the facility, and signs posted on the walls throughout the facility. Administrator Itzel Guevara was not available during today's visit. Facility manager Adriana Cisneros arrived to the facility to conclude the inspection.

The infection control inspection began with the receptionist Emily and ended with Adriana. The common areas were observed to be clean, including resident rooms, and staff and visitor bathrooms. Soap and towels, and hand washing signs were visually posted. The facility has cleaning procedures and protocols in place, which include staff and housekeeping cleaning common areas, elevator, and doorknobs (2x) a day.

The facility has documentation of all vaccination records and other pertinent information pertaining to COVID-19, in staff and resident files. All new employee hires and new resident admits, will be properly screened, and provided a negative COVID test, prior to entering the facility. Facility prefers vaccinated staff and new residents; but it is not required. The facility only surveillance test, when there are symptoms from staff or residents. If there are any signs or symptoms from residents or staff, the facility has a rapid test kits in place, and uses a COVID testing agency if needed. The Administrator receives departmental emails. Facility continues to provide and conduct training to staff in relation to COVID-19 and other required training. There is medication training scheduled in the next (2) weeks. There is a sick

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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 HILLS RETIREMENT CTR INC	FACILITY NUMBER: 197609631
	VISIT DATE: 09/15/2022

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sick leave policy. The facility does not have staffing issues. There are designated rooms for potential positive COVID residents because the facility has private rooms. PPE supplies were inspected and have over (30) day supply. The facility continues to implement the best practices for the facility; to ensure the health and safety of residents and staff.

The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview was conducted and copy of report was provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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