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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427608
Report Date: 12/23/2022
Date Signed: 12/23/2022 11:57:35 AM


Document Has Been Signed on 12/23/2022 11:57 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:GOLDEN YEARS ELDERLY CARE INCFACILITY NUMBER:
366427608
ADMINISTRATOR:MANZAT, DANIELAFACILITY TYPE:
740
ADDRESS:12772 HAWKS HILL STREETTELEPHONE:
(760) 951-5043
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:6CENSUS: 1DATE:
12/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Daniela and Claudiu Manzat, AdministratorsTIME COMPLETED:
12:15 PM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Golden Year Elderly Care Facility unannounced to conduct the Annual Inspection with a focus on Infection Control. LPA introduced self and stated the purpose of the visit. LPA was greeted and invited inside by Administrator Daniela Manzat. Staff member Claudiu was present and introduced himself during visit. Both observed wearing proper PPE. LPA was asked to sign in and if LPA had any symptoms. Administrator reported that the current census is 1. The resident is currently at Tender Hearts. Resident is fully vaccinated.

During the inspection, LPA Coleman was walked through the facility. COVID station was observed upon entry and signing in. Facility was observed to be orderly and free of obstructions. Also, comfortable in temperature. Signs for Infection Control were observed posted through out facility. Fire Alarms were tested and found operational. Carbon Monoxide Alarms were plugged in, tested and operational. Fire Extinguisher observed in the laundry room, fully charged. Last inspected March 2022. Restrooms, clean and equipped with hand soap, paper products and waste baskets. Resident rooms orderly, furnished with sufficient lighting.

LPA interviewed Administrator pertaining to the facility's infection control measures and other health and safety concerns. LPA observed necessary signs posted in the facility, which were in accordance with the Department's guidelines. Administrator stated that the facility is equipped with sufficient PPE, hand hygiene supplies, and sufficient cleaning/disinfecting provisions. Extra supplies located in hallway closet. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation of residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

Kitchen observed to have secure drawer for sharp objects. Chemicals observed in the garage with secure entry way. The garage is where the emergency supplies of PPE and food were observed. Medications are centrally located in a closet near the living room. Resident file reviewed and observed to have completed emergency contact information.

Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, and no deficiencies were noted.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2022
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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