306001607-8-22-2024-22-AS-EKIM-D8DR95-20240822124858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001607
Report Date: 08/22/2024
Date Signed: 08/22/2024 12:49:05 PM

Document Has Been Signed on 08/22/2024 12:49 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	GOLDEN YEARS ASSISTED LIVING		FACILITY NUMBER:	306001607
ADMINISTRATOR:	PAUL CHIERICHETTI		FACILITY TYPE:	740
ADDRESS:	4995 WOODCREST CR.		TELEPHONE:	(714) 223-0992
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 6	DATE:	08/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Paul Chierichetti		TIME COMPLETED:	01:00 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 August 22, 2024, at 8:50am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator (AD) Paul Chierichetti and explained the purpose of the visit.

The facility is licensed to operate for six (6) non-ambulatory and have a hospice waiver for three (3) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, four (4) bathrooms, living room, family area, dining room, kitchen, attached 2-car garage, and an outside covered patio area.

LPA Kim toured indoor and outdoor of the physical plant with AD Chierichetti. There are no obstructions or bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, Resident Room 5, and Resident Room 6. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 106.3 degrees F and 111.7 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, water, and supplies are stored in the garage. The facility has one (1) fire extinguisher that is charged and was serviced on June 11, 2024 and smoke/carbon monoxide detectors were operable.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOLDEN YEARS ASSISTED LIVING	FACILITY NUMBER: 306001607
	VISIT DATE: 08/22/2024

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
26
27
28
29
30
31
32

During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The facility conducts Fire/Safety Drill quarterly and was last conducted on June 27, 2024. A working telephone (714-646-9022) remains available. First Aid Kit contained all the necessary elements.

LPA conducted an audit of resident files (R1-R6), staff files (S1-S2) and medication and medication administration review. LPA Kim conducted 1 resident interviews and 2 staff interviews.

A deficiency was cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6 Chapter 8).

An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator Paul Chierichetti.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/22/2024 12:49 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOLDEN YEARS ASSISTED LIVING	FACILITY NUMBER: 306001607
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above. LPA observed R2 is diagnosed with dementia and their physician's report was on 11/24/2021 and R4 is diagnosed with dementia and their physician report was on 09/28/2020. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2024
	Plan of Correction
1 2 3 4	Licensee states they will provide a current Physican's report for R2 and R4 to CCLD via email to edward.kim@dss.ca.gov by POC due date September 5, 2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3