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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004556
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:27:34 PM


Document Has Been Signed on 04/28/2022 02:27 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:GOLDEN YEARS RESIDENTIAL CAREFACILITY NUMBER:
306004556
ADMINISTRATOR:REYES, JUAN JOSEFACILITY TYPE:
740
ADDRESS:25776 PERICLESTELEPHONE:
(949) 648-1303
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:August Revollar, caregiver
Rosa Rymalde, caregiver
Juan Reyes, administrator		TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by caregivers August Revollar and Rosa Nino Rymalde after explaining the purpose of the visit and being screened for COVID-19. Administrator Juan Reyes was notified of the visit by staff and arrived later to assist with the visit.

At approximately 1:25am, LPA accompanied by caregiver toured the inside and outside of the facility. There are currently six (6) residents in care, including two (2) on hospice. Residents are observed relaxing in the common areas or in their bedrooms and appear clean and well taken care of. The bedrooms include all necessary components. The bathroom is equipped with grab bars and slip mats. Hand washing signs are being displayed. Facility appears to be clean, sanitary and free of odors in all areas inspected. Staff present is observed to be correctly associated in Guardian.

Sharp instruments are kept in a cabinet secured by a key lock as well as cleaning supplies and toxic substances. LPA observed the facility has COVID-19 Precautions posters and required department postings. Facility has an adequate supply of PPE. LIC808 Mitigation Plan has been submitted. LPA has infor;edd\ed caregiver that a new Infection Control document has been released and will have to be submitted to Community Care Licensing by 06/30/2022 and will notify administrator also.

LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored and locked in a cabinet. LPA toured the outside of the facility. The perimeter gates are self-latching and can easily be opened in an evacuation.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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