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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610238
Report Date: 07/22/2024
Date Signed: 07/22/2024 12:33:01 PM


Document Has Been Signed on 07/22/2024 12:33 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:
07/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Oscar BarreraTIME COMPLETED:
01:00 PM
NARRATIVE
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On 07/22/2024 Licensing Program Analyst (LPA) Evelin Rios conducted a case management - deficiencies visit in connection to complaint control # 31-AS-20230503160359. LPA was greeted by staff #1(S1) who contacted the administrator, Oscar Barrera. LPA informed the administrator the reason for the visit was to conduct a Case Management visit. Oscar informed LPA they would be able to meet LPA at the facility at later time.

LPA conducted a physical plant inspection to assure the health and safety of the residents. LPA did not observe any health and safety concerns or issues.

On a subsequent visit conducted on 05/14/2023 for complaint control # 31-AS-20230503160359 it was revealed in a staff interview regarding resident #1(R1) that R1 was observed hitting themselves against walls and a door when staff would assists R1 with bathing, dressing or toileting. A staff interviewed revealed when R1 would become aggressive R1 would be placed in the hospice bed with the bed rails up and R1 would hit the rails hard with their body and arms. Administrator and co administrator, Marina Barrera conformed R1's aggressive behavior surrounding bathing. On 07/22/2024 LPA Rios confirmed with the administrator R1 was not on Hospice. LPA confirmed R1 did not have a hospice bed with bed rails in the facility but R1's roommate resident #2 (R2) was on hospice and a hospice bed with bed rails was in the shared bedroom at the time. Sun downing behavior identified as sometimes on R1's Physician's Report.

Deficiencies cited on LIC 809 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: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
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 07/22/2024 12:33 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: 07/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2024
Section Cited
CCR
87608(a)(5)

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(a) ... Postural supports may be used under the following conditions.(5)Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This requirement is not met as evidenced by:
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R1 is no longer in the facility. Licensee/ Administrator will conduct a vendorized training on the regulation 87608(a)(1)-(5). Administrator will provide a the training company used with the training material covered and a sign in sheet of staff that participated in the training to LPA by POC Due date 08/16/2024
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Based on interviews conducted, the facility restrained R1 in a bed with bed rails to prevent R1 from injuring staff. R1 was observed hitting themselves against bed rails which posed an immediate health, safety and personal rights risk to residents in care.
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Type A
08/16/2024
Section Cited
CCR87608(a)(3)

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(a) ... Postural supports may be used under the following conditions.(3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement is not met as evidenced by:
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R1 is no longer in the facility. Licensee/ Administrator will conduct a vendorized training on the regulation 87608(a)(1)-(5). Administrator will provide a the training company used with the training material covered and a sign in sheet of staff that participated in the training to LPA by POC Due date 08/16/2024
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Based on interviews conducted, the facility placed R1 in a bed with bed rails. Review of R1's file did not have a written order from a physician indicating the need for the postural support which posed 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: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
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