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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005506
Report Date: 08/27/2021
Date Signed: 09/01/2021 07:20:04 PM

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-PROSPECTFACILITY NUMBER:
306005506
ADMINISTRATOR:CHIERICHETTI, MARYFACILITY TYPE:
740
ADDRESS:4232 PROSPECT AVETELEPHONE:
(714) 343-8815
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 6DATE:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Liz Acedo and Arnel LeguaTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. The visit was conducted to assess Infection Control due to the COVID19 pandemic. Upon arrival LPA met with Staff Liz Acedo and Arnel Legua. Administrator Mary Chierichetti was texted by staff to let her know of LPA's visit. During the visit LPA toured the facility with Liz Acedo and the following was observed:

Covid signage was posted at the front entrance of facility with a sanitization station. LPA's temperature was taken upon arrival and a sign in sheet was made available. Facility has required Department postings. Licensee will need to send updated Administrator Certificate for Mary Chierichetti as the one posted in the facility expired 10/2020. LPA toured all resident rooms. Rooms were clean and sanitary. All restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Residents were watching tv, having lunch and resting in their rooms. Licensee has required Mitigation plan and Emergency Disaster Plan. LPA observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff. Administrator is reminded to review PIN 20-17.2-ASC in regards to Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. PIN 21-32-ASC provides Updated Staff Testing and Masking Guidelines. No deficiencies noted during visit. An exit interview was conducted with and a copy of this report was provided to Ms. Acedo.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
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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