197610451-9-13-2024-31-AS-MSPH-D93UPG-20240913154529

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610451
Report Date: 09/13/2024
Date Signed: 09/13/2024 03:46:28 PM

Document Has Been Signed on 09/13/2024 03:46 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:	MERLY DEE		FACILITY TYPE:	740
ADDRESS:	1117 ERWIN DRIVE		TELEPHONE:	(661) 992-1697
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 4	DATE:	09/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	MERLY DEE		TIME COMPLETED:	01:15 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) Melissa Spaeth conducted an unannounced annual visit on 9/13/2024 and was greeted by the Administrator Merly Dee. LPA stated the purpose of the facility was to conduct an annual inspection. Staff confirmed there are four residents living at the facility. The facility is licensed for six non-ambulatory residents. LPA and the caregiver toured the facility at 10:45 am until 11:15 am. Common Areas/Dining Room – LPA observed the living room contained comfortable seating along with a television. The dining room area contained a dining room table and chairs. Kitchen – LPA observed the kitchen was neat and clean. The knives were securely locked in a kitchen drawer. The facility contained a two day supply of perishable food and a seven day supply of non-perishable food items. A fire extinguisher is also located in the kitchen. Resident Bedrooms - There are five bedrooms in the home which are furnished with a bed, linens, night stand, chest of drawers and a closet. Hallway Closets – LPA observed a kitchen closet which contained medications and first aid kit. A hallway closet contained linens. Bathrooms - LPA observed the three bathrooms contained hand soap, paper towels, grab bars, and slip resistant mat. LPA tested the water temperature at 10:55 am, which was 105.0 degrees F. Continued on 809-C

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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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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: 09/13/2024

NARRATIVE

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Laundry Room – LPA observed the room was locked and contained washer and dryer.

Smoke/Carbon Monoxide Detectors – The detectors were tested at 11:40 am and were operable.

Backyard - LPA observed the backyard which has a shaded area with seating.

Garage - LPA observed the garage was locked. The laundry detergent, cleaning solutions, and emergency water were located in the garage.

Delayed Egress Devices - LPA observed delayed egress devices on all exit doors and all devices were properly working.

Storage Buildings - There are two storage buildings in the backyard. One building was locked and contained tools. The other building is a designated rest area for staff.

LPA reviewed client records at 11:45 am until 12:15 pm LPA reviewed staff records at 12:15 pm until 12:40 pm. LPA reviewed the residents’ medications at 1:00 pm.

There are no deficiencies to report. Exit interview was conducted and a copy of the signed report was given.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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