197609631-9-22-2023-31-AS-JGTN-CVVTP7-20230921145353

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609631
Report Date: 09/21/2023
Date Signed: 09/22/2023 07:41:55 AM

Document Has Been Signed on 09/22/2023 07:41 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
WOODLAND HILLS S.ASC, 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: 37	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Adriana Cisneros - Office Manager		TIME COMPLETED:	03:00 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 met with Office Manager Adriana Cisneros for a One (1) Year Required visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 9:32 AM and the following was noted: There is only one entrance being utilized at the facility, the front main entrance door. There are required poster posted at the main door. Screening area is located immediately upon entrance. There is also a sign in sheet, hand sanitizer, gloves and masks available. The facility had submitted and approved Mitigation and Infection plan. There are hand sanitizing stations all over the facility. There are signs to wear a mask 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 common bathrooms and all over the common areas of the facility. The facility have designated visitors' area at the front yard. The facility has sufficient stock of PPE in the office upstairs. The facility is a two (2) storey building with shared and private bedrooms and bathrooms. Second floor is used only as an office/storage for staff use only. All indoor and outdoor passageways/exits were free of obstruction. There is no body of water in the facility. The facility maintains a comfortable temperature at 75°F. The facility's smoke alarms are hard wired and tested regularly every month. Fire inspection was last done on 08/14/23 and valid until 05/31/26. The facility is also equipped with sprinkler system which was last tested on April 2023 and valid for five (5) years. Fire extinguishers are located all throughout the facility and were last serviced on 10/12/22. Fire Drill was last conducted on 07/08/23. (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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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

FACILITY NAME: GOLDEN HILLS RETIREMENT CTR INC	FACILITY NUMBER: 197609631
	VISIT DATE: 09/21/2023

NARRATIVE

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(continued from LIC 9099)

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient supply of perishable and non-perishable food and properly stored at the facility. Knives, cleaning agents, and other potentially hazardous items were locked and inaccessible.

Bedrooms: The resident bedrooms were properly furnished with one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

Bathrooms: LPA observed all bathrooms to be clean, properly supplied and equipped with functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. There are four (4) common shower rooms in the facility, all observed to be clean and in good repair. Hot water was measured in random bathroom at the range of 117.1°F to 119.8°F and observed to be within the required range.

Common Areas: These includes the living room, dining room and outdoor areas. Facility common areas appeared to be clean and appropriately furnished at the time of this visit, no accessible hazards were observed.

Medications were observed to be stored in designated Medication room. The Medication room was observed to be locked at the time of visit. There is a complete set of first aid kit in the Medication room.

Resident/Staff File Review: LPA reviewed records of five (5) random residents and five (5) staff. Resident and staff records appeared to be complete and updated.

Laundry room located in the underground level of the facility and observed to be locked during visit.

There is no immediate health and safety hazard during this visit.

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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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