306006417-5-23-2024-22-AS-RMAZ-D5JPMH-20240523112621

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006417
Report Date: 05/23/2024
Date Signed: 05/23/2024 11:26:28 AM

Document Has Been Signed on 05/23/2024 11:26 AM - 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 GROUP		FACILITY NUMBER:	306006417
ADMINISTRATOR:	ATTRAH, AMEER		FACILITY TYPE:	740
ADDRESS:	507 S. CITADELL LANE		TELEPHONE:	(949) 994-2900
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92806
CAPACITY:	6	CENSUS: 5	DATE:	05/23/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ameer Attrah		TIME COMPLETED:	11:30 AM

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) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at facility was greeted and granted entry. LPA met with Ameer Attrah, Administrator and explained the visit. A change of ownership application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden resident was submitted to CCL on 09/13/23. Structure: The facility is a one story house with a detached garage with 1 caregiver room, 4 resident bedrooms, 3 full bathrooms, a living rooms, a dining room/kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with seating for the residents and an exit walkway on each side of the house. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms will accommodate 6 residents with 2 private rooms and 2 shared room accommodating two residents. Bedrooms Staff: Designated bedroom for live-in staff with a bathroom. Bathrooms: Facility has three full bathrooms. All bathrooms have a working toilet, wash basin, walk in shower. Linens & Hygiene Supplies: Adequate supply of linen in storage. Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week. Food Service: Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested, and found operational. 1 fire extinguishers mounted in kitchen, charged Continued on LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOLDEN YEARS GROUP	FACILITY NUMBER: 306006417
	VISIT DATE: 05/23/2024

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and dated December 08, 2023. Appliances: Gas five burner stove, single oven, refrigerator, freezer,microwave, dishwasher, washer, and dryer are clean and noted to be operational. Toxins: All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked in storage closet. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 114.2 Fahrenheit degrees in facility bathrooms. Medications, First-Aid Kit & Book: Medication is stored in a medication cart in kitchen and First Aid kit stored in kitchen. First aid book is mounted on the wall of the kitchen. Resident & Staff Files: Records will be kept locked in storage cabinet located in kitchen/office. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation. Fire clearance: Was approved on April 04, 2024. Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued.

Exit interview was conducted and a copy of this report was left with the applicant.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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