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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427602
Report Date: 01/17/2024
Date Signed: 01/17/2024 02:32:02 PM


Document Has Been Signed on 01/17/2024 02:32 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: 4DATE:
01/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Rosie GaxiolaTIME COMPLETED:
02:34 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Anna Bueno annd Bianca Wolcott conducted an unannounced visit to the facility for the investigation of complaint number: 56-AS-20240108114146. LPAs met with staff who were informed of the reason for the visit.

During today's visit, LPAs interviewed relevant parties, made facility observations, and reviewed records. It was observed that Resident 1 is located in a room that is labeled as a staff room. This pose as a potential health and safety risk to resident in care. Refer to LIC 809D for deficiency cited.

Technical advisory was provided for additional concerns during today's visit. LPAs phoned Licensee and discussed the concern. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Rosie Gaxiola.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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 2


Document Has Been Signed on 01/17/2024 02:32 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: GOLDEN YEARS RESIDENTIAL CARE
FACILITY NUMBER: 366427602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2024
Section Cited
CCR
87202(a)

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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshall.
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Licensee shall relocate Resident 1 to a resident room approved by the Fire Marshal. Licensee shall provide proof of correction no later than end of POC date.
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This requirement was not met as evidenced by:

Based on LPA observations and Staff interviews, Resident 1 was observed in a room next to the kitchen labeled as staff room. This pose as a potential health and safety risk to resident in care.
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2