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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427602
Report Date: 10/21/2022
Date Signed: 10/21/2022 01:10:49 PM


Document Has Been Signed on 10/21/2022 01:10 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:GOLDEN YEARS RESIDENTIAL CAREFACILITY NUMBER:
366427602
ADMINISTRATOR:ALEXANDRU POPESCUFACILITY TYPE:
740
ADDRESS:7890 SAN BENITO STREETTELEPHONE:
(909) 335-8335
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY:6CENSUS: 5DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Maria Rif, Staff MemberTIME COMPLETED:
01:15 PM
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LPA Amber Coleman (LPA Coleman) and LPA Anna Bueno (LPA Bueno) arrived that The Golden Years Residential Care Facility to make an unannounced visit to conduct the Annual Inspect with emphasis on Infection Control. Staff Member (S1) answered the door and invited LPA's inside facility. LPAs and S1 introduced each other and explained the purpose of the visit. S1 showed LPA's where to sign in for the visit. LPA observed thermometer, disinfectant solutions and masks available to visitors as they make entry.

S1 and LPA's walked through the facility to ensure client's safety and see the facility in use. S1 took LPA's in the kitchen which was free of clutter and debris. Sharp items were locked and out of sight. S1 reported the current census is 3 and the capacity is 6. During the visit 2 client's were present. LPA's observed the living room, dining rooms and client's rooms. LPA's observed the fire alarms to be working properly. Each bathroom was equipped with sufficient soap and paper towels. Each room was stocked with paper towels, waste baskets and clean linens. During the walk through of the backyard grounds, LPA observed a shaded area with accessible patio furniture. LPA observed no bodies of water on property. Exits/Walkways around the home with proper signages and free of hazards. Infection Control Signs were also seen around the facility.

During this visit, technical Violations were issued for 3 fire extinguishers that had not been inspected since September 16th, 2021. As well as 2 converted staff rooms. Licensee will be submitting and updated facility sketch and proof of updated fire extinguisher inspection no later than the October 29th, 2022.

Exit interview was conducted and discussed with S1 and a copy of this report LIC 809 was provided during this visit.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
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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