197610451-8-31-2023-31-AS-MSPH-CV8VAK-20230831161603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610451
Report Date: 08/31/2023
Date Signed: 08/31/2023 04:16:07 PM

Document Has Been Signed on 08/31/2023 04:16 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	1ST GOLDEN SENIOR CARE HOME		FACILITY NUMBER:	197610451
ADMINISTRATOR:	DEE, MERLY		FACILITY TYPE:	740
ADDRESS:	1117 ERWIN DRIVE		TELEPHONE:	(661) 992-1697
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 0	DATE:	08/31/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Merly Dee		TIME COMPLETED:	12:40 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	On 8/31/2023, Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced Pre-Licensing visit to this facility and met with the Licensee. This is a new application and a fire clearance dated 08/08/2023 was received for six (6) non-ambulatory residents. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6. Component III was conducted with the applicant from 10:20 am until 11:00 am Today’s site visit consisted of LPA touring the physical plant inside and outside from 11:00 am until 11:45 am. LPA Spaeth observed the following: Living/Dining Room – LPA observed the living room and dining room are combined. The living room area contained two couches, chairs, and a television. The dining room contained a dining room table with chairs. Kitchen - The facility contained a seven day supply of non-perishable food and a two day supply of perishable foods. A locked kitchen cabinet underneath the kitchen sink contained the cleaning supplies. There is a locked drawer for knives. A fire extinguisher is also located in the kitchen. Appliances in the kitchen appeared to be functional. Backyard - The backyard contained comfortable seating for residents. The side gate leading from the backyard to the front yard was not locked. There are two sheds located in the backyard. One shed was empty and the other shed contained additional folding chairs. Continued - 809C

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: 1ST GOLDEN SENIOR CARE HOME	FACILITY NUMBER: 197610451
	VISIT DATE: 08/31/2023

NARRATIVE

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Bedrooms - There are five bedrooms which contained bed, linens, night stand, lamp, chest of drawers, a chair and a closet. Bedroom #5 is a designated shared room. Bedroom #5 is the master bedroom and master bath combination.

Bathrooms- There are three bathrooms which contained hand soap, paper towels, trash can, grab bars, and slip resistant mats. The water temperature was recorded at 11:15 am and was 105.0 degrees F.

Hallway - The hallway closet was locked and contained resident hygiene items, PPE, first aid kit, and will be the designated location for residents’ medications. There is a two drawer locked cabinet and will contain resident and staff records. A linen closet located near Bedroom #5 contained clean linens.

Laundry Room – the laundry room was locked and LPA observed the washer and dryer located in this area. The laundry soap was stored in a cabinet.

Garage- LPA observed the emergency food and water were located in this area.

The smoke and carbon monoxide detectors were tested at 11:45 am and were operable. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all exit doors. The facility was clean and appears to be in good repair.

This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. Exit interview was conducted with Licensee. A copy of this report was signed and delivered.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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