366427602-12-6-2024-56-AS-RHSL-DBPTD8-20241206133756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366427602
Report Date: 12/06/2024
Date Signed: 12/06/2024 01:38:16 PM

Document Has Been Signed on 12/06/2024 01:38 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GOLDEN YEARS RESIDENTIAL CARE		FACILITY NUMBER:	366427602
ADMINISTRATOR/ DIRECTOR:	ALEXANDRU POPESCU		FACILITY TYPE:	740
ADDRESS:	7890 SAN BENITO STREET		TELEPHONE:	(909) 335-8335
CITY:	HIGHLAND	STATE: CA	ZIP CODE:	92346
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:02 AM
MET WITH:	Administrator, Iren Creighton		TIME VISIT/ INSPECTION COMPLETED:	01:40 PM

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	On 12/06/2024, Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator Iren Creighton. LPA introduced self, stated the purpose of the visit and gained entry to the residence. LPA was informed that there are currently 5 residents in care, two (2) bedridden and (3) non-ambulatory. The facility has 6 bedrooms, 4 bathrooms, kitchen, dining area, living room, office, laundry, attached garage and backyard. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 77 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 115 degrees Fahrenheit. The facility is equipped with operational smoke detectors, charged fire extinguishers and first aid kit. LPA did not observe an identifiable carbon monoxide detector. A deficiency was cited. Posters such as; the personal rights, emergency disaster plan, CCLD complaint poster and ombudsman were posted in a common area. Cleaning supplies, toxins and other dangerous items were kept locked and inaccessible to residents. LPA observed a pair of scissors and knives to be in unlocked kitchen drawers. A deficiency was cited. There was a designated storage space for resident/staff files. Medications were observed to be locked and inaccessible to residents. LPA observed two (2) resident files without physician's orders for medication. A deficiency will be cited. There is no swimming pool, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Karen Clemons	TELEPHONE: (951) 836-2748
Renese Howell-Small	TELEPHONE: (951) 248-2222
	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

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 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN YEARS RESIDENTIAL CARE	FACILITY NUMBER: 366427602
	VISIT DATE: 12/06/2024

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
26
27
28
29
30
31
32

Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly.

Yards/Outside: One shaded patio, side gate with self-latching handle on the left side of the house that leads into the backyard.

Record Review: LPA reviewed staff and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed two (2) staff without First Aid/CPR certification and three (3) staff without physician's reports and tuberculosis clearance. A deficiency was cited.

Five deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and Appeal Rights were discussed and copies were provided to Adminisrator Iren Creighton.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-Small	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 12/06/2024 01:38 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN YEARS RESIDENTIAL CARE	FACILITY NUMBER: 366427602
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above by not ensuring facility had an identifiable carbon monoxide detector, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/07/2024
	Plan of Correction
1 2 3 4	Administrator purchased and installed a carbon monoxide detector during the facility visit and LPA observed it to be operable.

Section Cited

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that staff members have completed First Aid/CPR certification, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2024
	Plan of Correction
1 2 3 4	Administrator will register the staff for First Aid/CPR certification and send proof to LPA by Plan of Correction due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 836-2748
Renese Howell-Small	TELEPHONE: (951) 248-2222
	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 12/06/2024 01:38 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN YEARS RESIDENTIAL CARE	FACILITY NUMBER: 366427602
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that staff have a physician's report and tuberculosis clearance, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2024
	Plan of Correction
1 2 3 4	Administrator will make doctor's appointments for staff and send proof of physician's resport with tuberculosis clearance to LPA by Plan of Correction due date.

Section Cited

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring resident files contain physician's orders for residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2024
	Plan of Correction
1 2 3 4	Administrator placed several phone calls to responsible parties to obtain physician's orders during the facility visit. Administrator will submit physician's orders for residents file to LPA by the Plan of Correction due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 836-2748
Renese Howell-Small	TELEPHONE: (951) 248-2222
	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 12/06/2024 01:38 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN YEARS RESIDENTIAL CARE	FACILITY NUMBER: 366427602
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not ensuring scissors and knives were kept inaccessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2024
	Plan of Correction
1 2 3 4	Administrator removed items from accessible drawer and placed them in a locked cabinet during the visit. Administrator will conduct employee training and submit proof to LPA by the Plan of Correction due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 836-2748
Renese Howell-Small	TELEPHONE: (951) 248-2222
	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6