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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610238
Report Date: 05/14/2024
Date Signed: 05/14/2024 04:27:52 PM


Document Has Been Signed on 05/14/2024 04:27 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:
05/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:44 PM
MET WITH:Oscar BarreraTIME COMPLETED:
04:30 PM
NARRATIVE
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On 05/14/2024 Licensing Program Analyst (LPA) Evelin Rios conducted a case management deficiencies visit in conjunction to a subsequent complaint visit control # 31-AS-20230503160359.

On initial complaint visit conducted on 05/09/2023 it was reported by administrator and three staff, resident #1(R1) had a swollen wrist. The administrator noted the significance, took a picture and sent picture to R1's family member. It was reported to the facility at that time that R1 would be taken to Urgent Care by R1's family member because they believed R1 had sustained an injury. LPA reviewed facility incident reports and could not locate one with the information reported on interviews. Administrator states they cannot remember if a report was not made to Community Care Licensing Division when the incident was reported to have occurred in April of 2023 prior to LPA's initial complaint visit 05/09/2023.

Do to concerns made to LPA about emergency procedures, LPA requested emergency drill training documentation conducted every quarter. The administrator revealed that although the do conduct emergency drills they do not have documentation.

Deficiencies cited on LIC 9099 D. Appeal Rights provided. Exit Interview conducted. Copy of report provided via email.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
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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Document Has Been Signed on 05/14/2024 04:27 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: 05/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2024
Section Cited
CCR
87211(a)

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87211 (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to...
This requirement is not met as evidenced by:
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Licensee will fill out an incident report for the incident involving resident #1(R1) that was said to have occured April 2023 and provide a statement of understanding of the cited regulation to LPA by POC due date May 24, 2024.
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Based on record review and interviews the licensee did not comply with the section cited above in not reporting timely to CCLD the events that occurred on April 2023 which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/31/2024
Section Cited
HSC1569.695(c)

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(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter...While a facility may provide an opportunity for residents to participate in a drill, it shall not require... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
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Licensee stated they are due for a drill, so licensee will send LPA documentation of the drill conducted which will include the date, the type of emergency covered by the drill, and the names of staff participating in the drill by POC due dae 05/31/2024
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This requirement is not met as evidenced by:
Based on record review and interviews the licensee did not comply with the section cited above not documented quarterly drills which poses a potential health, safety or personal rights risk to persons 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: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
LIC809 (FAS) - (06/04)
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