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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610238
Report Date: 09/04/2024
Date Signed: 09/04/2024 11:48:21 AM


Document Has Been Signed on 09/04/2024 11:48 AM - 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:
09/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Oscar BarreraTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst( LPA) Evelin Rios arrived at the facility. LPA conducted a case management - deficiencies visit in conjunction to complaint control #31-AS-20240826095917. LPA Rios spoke to the administrator Oscar Barrera and LPA explained the reason for the visit.

LPA observed two (2) staff in the facility with three (3) residents. LPA observed the facility staff schedule on the wall with staff names. LPA review of Guardian revealed staff #2 (S2) was not on the facility roster. LPA's interview with S2 revealed they are live-in staff that works at night and has been working at the facility for two months. LPA's interview with two (2) out of three (3) residents revealed S2 provides them assistance with activities of daily living such as meals and incontinent care. LPA requested staff records from administrator, and they provided a clearance letter for S2, but it was for another licensed facility. According to the administrator a Transfer request has not been submitted to the Regional Office. Administrator also stated staff moved into the facility this week.

Deficiency cited. Appeals right provided. Copy of report provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
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 09/04/2024 11:48 AM - 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: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/05/2024
Section Cited
CCR
87355(e)(2)

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e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or... This requirement is not met as evidenced by:
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The administrator will remove Staff #2 (S2) and not allow them to return to the facility until association or requested transfer is complete. The adminsitrator will submit an updated LIC500 and a screen grap of the facility roster on Guardian by POC due date 09/05/2024.
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Based on interviews and record review, the licensee did not comply with the section cited above as the facility did request a transfer of a criminal record clearance for one (1) staff #2(S2) present at the facility today which poses an immediate Health, Safety or 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: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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