197610238-3-4-2022-31-AS-MRUZ-CC7QKN-20220304111433

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610238
Report Date: 03/02/2022
Date Signed: 03/04/2022 11:15:22 AM

Document Has Been Signed on 03/04/2022 11:15 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 YEARS HOME		FACILITY NUMBER:	197610238
ADMINISTRATOR:	BARRERA, OSCAR & MARINA		FACILITY TYPE:	740
ADDRESS:	44315 CASA NOVA DR		TELEPHONE:	(661) 206-8026
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS:	DATE:	03/02/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Oscar Barrera		TIME COMPLETED:	11:25 AM

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	At 10:00 a.m., Licensing Program Analyst (LPA) Melissa Ruiz conducted an announced Pre-Licensing visit. This is a change of location application. Entrance interview with the Administrator Oscar Barerra was initiated. At the time of this visit, LPA was not screened for infection control. There was no infection control protocols in place. LPA observed three (3) residents at the facility. Fire Clearance dated 12/8/21 was received for six (6) residents, of which six (6) could be non-ambulatory. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following: The facility has six (6) bedrooms, four (4) of which are designated for resident use. Resident bedrooms were observed to be appropriately furnished. There are two (2) bathrooms in the facility, and all were observed to have non-skid mats and appropriate grab bars installed. No trash cans were observed to have closed tight fitting lids. The living room has a television and comfortable furniture. Resident and staff records will be stored in a cabinet in the office room. The fire extinguisher was last purchased on 2/1/21. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted by the entrance wall with other posting requirements. Medications are stored in a locked cabinet in the kitchen area. The first aid kit is readily available. LPA observed there to be a sufficient amount of perishable and nonperishable food. Facility appears to be clean, in good repair and kept at a comfortable temperature 69°F. Necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on doors. There is a shaded sitting area in the backyard. The backyard is fenced. There is a designated laundry room that stores linens, cleaning supplies and it leads to an attached garage which stores extra food and supplies. Component III was conducted with the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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 YEARS HOME	FACILITY NUMBER: 197610238
	VISIT DATE: 03/02/2022

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
26
27
28
29
30
31
32

On 10/19/21 LPA Ruiz spoke with the Administrator in which Administrator stated he wanted to move the facility to a new location. Administrator stated he was having issues with their current landlord and wanted to find a different home. LPA advised him on the process to change the facility location, which needed to be completed by Central Applications Bureau. Administrator stated he will send the required documentation to “Sacramento”.

On 2/17/22 LPA Ruiz arrived at the facility location to conduct an unannounced annual inspection. Upon arrival, LPA did not observe anyone at the facility. LPA proceeded to call the Administrator and LPA was informed that he has moved the facility to a new location, 44315 Casa Nova Drive, Lancaster CA 93536. LPA arrived at the “new location” mentioned above and the Administrator stated Golden Years Home had been operating at the new location since 12/31/2021. LPA discussed that although he submitted an application for a change of location, the process had not yet been completed. Administrator failed to inform LPA or Central Applications Bureau that Golden Years Home was already operating in a new location.

Based on the information above, Administrator has been issued a Notice of Operation in Violation of the Law and deficiencies issued based on California Code of Regulations, Title 22, or California Health and Safety Code. Deficiencies has been cleared with the completion of today’s pre-license visit.

The licensee will have to complete the following:

1. Follow their mitigation plan and implement an infection control procedure for visitors.

2. Ensure all staff is trained for infection control protocols.
3. Replace all trash cans that do not have closed tight fitting lids.
4. Purchase a new fire extinguisher.

Proof of completion of the items mentioned above will be sent to LPA Melissa Ruiz at Melissa.ruiz@dss.ca.gov. Upon the completion of the items listed above, this report will be forwarded to the Centralized Application Bureau (CAB) for approval. Exit interview was conducted with Administrator Oscar Barerra and a copy of this report was provided.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/04/2022 11:15 AM - 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN YEARS HOME	FACILITY NUMBER: 197610238
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/03/2022 Section Cited	1 2 3 4 5 6 7	1569.10 RCFE; license or permit; necessity No person, firm, partnership, association, or corporation within the state and no state or local public agency shall operate, establish, manage, conduct, or maintain a residential facility for the elderly in this state without a current valid license or current valid special permit therefor, as provided in this chapter. This requirement is not met as evidence by:
	8 9 10 11 12 13 14	Based on LPA observation, interviews and document review, the Administrator failed to obtain a license to provide care and supervision to 3 out of 3 residents which posses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3