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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610238
Report Date: 03/01/2023
Date Signed: 03/01/2023 03:39:03 PM


Document Has Been Signed on 03/01/2023 03:39 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:GOLDEN YEARS HOMEFACILITY NUMBER:
197610238
ADMINISTRATOR:BARRERA, OSCAR & MARINAFACILITY TYPE:
740
ADDRESS:44315 CASA NOVA DRTELEPHONE:
(661) 206-8026
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 3DATE:
03/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Oscare BarreraTIME COMPLETED:
03:50 PM
NARRATIVE
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On 03/01/2023 Licensing Program Analyst (LPA) Evelin Rios conducted a case management deficiencies visit in conjunction to a complaint conducted on 02/27/2023 control 31-AS-20230222103008.

On 2/27/2023 at 10:00 a.m. while LPA conducted a physical plant inspection LPA observed pill organizers filled with pills for three (3) out three (3) residents in care in the designated medicine cabinet located in the kitchen. Licensee states they will immediately discontinue the use of the pill organizer and keep pills in original medicine containers. LPA's review of personnel records revealed S1 is not associated to the facility. Licensee states S1 has been working at the facility for two years and was unable to submit documentation to have S1 associated. Records on file reveal S1 has been working for the facility since 2021. LPA and Licensee reviewed Licensee's Guardian account which reveals Licensee has been locked out and need to unlock account.

Deficiencies cited on LIC 9099 D. Civil Penalty Assessed, Civil Penalty Issued (refer to LIC421BG). Appeal Rights provided. Exit Interview conducted. Copy of report provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
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 2


Document Has Been Signed on 03/01/2023 03:39 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: GOLDEN YEARS HOME
FACILITY NUMBER: 197610238

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2023
Section Cited

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(c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another...licensed facility by providing the following documents to the Department: (1)... LIC 9182.. (2)A copy of the individual's...(3)Any other documentation required by the Department .
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Licensee immediately removed S1 from the schedule until association occurs. Licensee will submit a confirmation from Guardian to LPA showing the association has occurred to LPA by POC due date 03/02/2023.
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Based on observation and interview, Licensee did not comply with the above cited section as evidence by although S1 has criminal record clearance S1 has not been associated to the facility.
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Type A
03/02/2023
Section Cited

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(h) The following requirements shall apply to medications which are centrally stored:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
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Licensee immediately placed pills back into their original containers and removed 7-day pill organizer from kitchen. POC cleared on 02/27/2023.
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Based on observation and interview, Licensee did not comply with the above cited section by failing to maintain resident's medication in originally received container and instead used a pill organizer labeled for 7-days which poses an immediate health, safety and personal rights risk to residents in care.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2