197610238-10-3-2023-31-AS-ERIS-CW9UDX-20231003153017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610238
Report Date: 10/03/2023
Date Signed: 10/03/2023 03:30:25 PM

Document Has Been Signed on 10/03/2023 03:30 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 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: 4	DATE:	10/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Oscar Barrera		TIME COMPLETED:	03:40 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) Evelin Rios conducted an Annual Required visit and inspection of the facility. Fire Clearance dated 12/8/21 was received for six (6) residents, of which six (6) could be non-ambulatory. LPA met with the administrator, Oscar Barrera, and staff #1 (S1) and explained the reason for the visit. At approximately 10:30 a.m. LPA took a tour of the physical plant. Required postings were observed in the entry area. LPA observed the Administrator test the smoke alarms that are battery operated and interconnected at 11:13 a.m. There are two (2) carbon monoxide detectors, one (1) is installed by the dining and living area and the second is in the hallway by the bedrooms, they were observed to function properly. The fire extinguisher located by the kitchen was purchased on 03/10/2023 and observed fully charged. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked kitchen cabinet. LPA observed a lock box in the refrigerator for medication requiring refrigeration. LPA observed medications were locked in one of the kitchen cabinets. Bedrooms: There are six (6) rooms four (4) bedrooms are designated for residents' use. Rooms labeled #5 and #6 can be shared. LPA observed rooms that are occupied by residents to be properly furnished with appropriate bedding, linens and sufficient lighting. Facility sketch has bedroom labeled #2 designated as an office, LPA observed the room to be occupied by resident #1 (R1). Bathrooms: There are two (2) bathrooms designated for residents' use. Bathrooms were properly supplied with toilet paper, non-skid mats, pull up bars and had functional fixtures. At 11:11 a.m. hot water temperature was measured in the main bathroom at 113.3 degrees Fahrenheit. (Continued on LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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
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: 10/03/2023

NARRATIVE

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(LIC809-C)
Common Areas: These included the living room and dining area. The common areas were properly furnished, clean and clear of clutter. LPA opened two sliding doors, one (1) in a shared bedroom and the second in the dinning area leading to the backyard, the auditory alarms on the exit doors were off at the time of the visit.

Surrounding Grounds: The laundry room is by the bedrooms and observed locked. The laundry room leads to a storage room labeled #4 and a garage that has a deep freezer and a second refrigerator. Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. LPA observed the side gate held closed with a wire. Administrator stated he had already called someone to come out and fix the latch for the side gate.

Resident Files: At approximately 11:30 a.m. LPA conducted a file review of resident records to insure compliance of licensing forms. LPA review of records revealed resident #4 (R4) is "bedbound" and the facility has fire clearance for non-ambulatory residents. Administrator stated R4's records are incorrect.

Staff Files: At approximately 1:06 p.m. LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: At approximately 1:53 p.m. medication and Centrally Stored Medication Records were reviewed for storage and documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D). Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/03/2023 03:30 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: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in two (2) out of four (4) residents by not obtaining fire clearance for resident #4 (R4) who records indicate they are bedridden before admitting them to the facility and for resident #1 (R1) who is occupying a room initially designated as an office which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	Licensee will submit an LIC 200 indicating change of amb. status with an updated facility sketch indicating which bedrooms need fire clearance to the department by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

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