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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610238
Report Date: 02/27/2023
Date Signed: 02/27/2023 04:58:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/22/2023 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20230222103008
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:
02/27/2023
UNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Oscar BarreraTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Residents are receiving medication not prescribed
Utensils/pans are not in good condition for residents
INVESTIGATION FINDINGS:
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On 2/27/2023 at 9:16 a.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility in response to the above mentioned allegations. LPA was granted entry into the facility by Licensee Oscar Berrera. LPA met with Marina Berrera the Administrator, shortly after and explained the reason for the visit. From 9:16 a.m. – 10:00 a.m. LPA conducted a physical plant inspection to assure the health a safety of the clients.

Allegation #1: Residents are receiving medication not prescribed.
It is alleged resident #2 (R2) is being given CBD that was given to facility by R2's family member. At 11:07 a.m. LPA and Licensee did a pill count of R2's medication and during count, CBD was observed and is recorded as a pill given to R2 on Lic 622 Centrally Stored Medication record. Licensee and LPA counted 20 pills for a bottle labeled with 40 pills. Licensee stated they had requested a prescription from R2's family member and had not received it. Family member confirmed they have not provided documentation form R2's physician for CBD use. Based on observation and interview this allegation is deem Substantiated.
(Continued LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 31-AS-20230222103008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2023
Section Cited
CCR
87303(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Licensee stated they will replace pots and pans with new ones they already have. Licensee will send a picture of the replacement pot and pans to LPA by POC date 03/03/2023.
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Based on observation and interview, Licensee did not comply with the above section by failing to maintain pot and pans in good repair, which poses a potential 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: 02/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/22/2023 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230222103008

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:
02/27/2023
UNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Oscar BarreraTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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2
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9
Staff are not properly destroying residents medications.
Staff are over medicating resident
INVESTIGATION FINDINGS:
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On 2/27/2023 at 9:16 a.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility in response to the above mentioned allegations. LPA was granted entry into the facility by Licensee Oscar Berrera. LPA met with Marina Berrera the Administrator, shortly after and explained the reason for the visit. From 9:16 a.m. – 10:00 a.m. LPA conducted a physical plant inspection to assure the health a safety of the clients.

Allegation #1: Staff are not properly destroying residents medications.
It is alleged old medication from residents who died or have left are being stored in the owner's office drawers and are not being destroyed. During a tour of the offie LPA requested Licensee to go through desk drawers. LPA observed only medication for curent residents. Licensee states he keeps medications that require a refill in his desk as a reminder. Licensee states he keeps his office door locked to keep medications inaccessible to residents in care. LPA did not observe medication for clients that are no longer in the facility. Based on this information this allegation is Unsubstantiated.
(Continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 31-AS-20230222103008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 02/27/2023
NARRATIVE
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Allegation #2: Staff are over medicating resident.
It is alleged resident #1 (R1) is being given extra medication when the resident cannot sleep. At 10:03 a.m. LPA and Licensee did a pill count for R1's medication. LPA and Licensee observed all pills accounted for. Pill count matched with pill amount and directions for how R1 should take the medication. Based on this information this allegation is Unsubstantiated.

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: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 31-AS-20230222103008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 02/27/2023
NARRATIVE
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Allegation #2: Utensils/pans are not in good condition for residents.
It is alleged pans and spoons used for residents have rust on them. During tour of the kitchen at 9:45 a.m. LPA observed pans and pots with oxidation and non stick coating completely off. Licensee, Oscar stated they had new pot and pans at home and that he will be brining them to the facility. Based on observation this allegation is deemed Substantiated.

Deficiencies cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted. Copy of report emailed for signature.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 31-AS-20230222103008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2023
Section Cited
CCR
87465(c)(1)
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(c)If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN...:(1)There is written direction from a physician...
This requirement was not met as evidence by:
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Licensee stated they will immediatley discontinue giving CBD to R2 until a physician's order is on file. Licensee will submitt a statement of understanding the cited regulation to LPA by POC due date 02/28/2023.
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Based on interview and observation the Licensee confirmed R2 is given CBD without a physician's order on file, 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: 02/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7