<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427602
Report Date: 01/29/2024
Date Signed: 01/29/2024 09:58:50 AM


Document Has Been Signed on 01/29/2024 09:58 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
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:
01/29/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Nick Vermani, administratorTIME COMPLETED:
10:00 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) Anna Bueno conducted an unannounced visit to the facility as a proof of correction visit for a deficiency issued on the 01/17/24. LPA met with administrator who was informed of the reason for the visit.

During today's visit, LPA met with and spoke with Highland Fire Prevention who verified that the former staff room adjacent to the kitchen has been cleared as a resident room. A Letter of Deficiency Citation Cleared is issued today.

No deficiency was issued during today's visit. An exit interview was conducted where this report was discussed with Mr. Vermani.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
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 1