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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800906
Report Date: 08/03/2022
Date Signed: 08/04/2022 10:16:27 AM


Document Has Been Signed on 08/04/2022 10:16 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,
, CA



FACILITY NAME:GOLDEN YEARS CAREFACILITY NUMBER:
565800906
ADMINISTRATOR:LARRY WAYNEFACILITY TYPE:
740
ADDRESS:1325 LANTANA STREETTELEPHONE:
(805) 383-1188
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 3DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Larry WayneTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kelly Dulek and Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 09:55AM. This annual had a specific emphasis on infection control practices and procedures. The LPAs met with Licensees Teresita and Larry Wayne and discussed the reason for the visit.

The LPAs, along with facility Licensee Larry Wayne, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPAs observed the required postings in the common area.

Two (2) fire extinguishers were observed to be fully charged and purchased on 02/27/2022. Smoke detectors were tested at 3:03PM and were functional at the time of the visit. Carbon monoxide detector was tested at 3:04PM and was functional at the time of the visit.

The backyard has a covered outdoor area equipped with furniture for resident use. LPAs observed the exterior of the facility to contain items on the side of the house and in the backyard. The licensee stated these items are going to be moved to a new shed or donated. There were no bodies of water noted. The garage was observed locked. At 10:02AM, LPAs observed a knife in the backyard area on top of a chair. At 10:05AM, LPAs observed a second knife on the outdoor patio on top of a ledge/shelf.

The laundry room was observed to be locked and contained items the Licensee stated will be donated. Licensee stated one of the laundry machines is currently inoperable and laundry is being taken off site to wash.


Report Continued on LIC 809-C
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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 11


Document Has Been Signed on 08/04/2022 10:16 AM - 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,
, CA


FACILITY NAME: GOLDEN YEARS CARE
FACILITY NUMBER: 565800906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 2 facility staff are not vaccinated and not in compliance with the testing requirements outlined in PIN 21-32.1-ASC which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 08/04/2022
Plan of Correction
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Licensee agreed to submit a plan outlining how facility staff will come into compliance with all CCLD PINs and Public Health Orders applicable to the facility operation by POC due date.
Type A
Section Cited
CCR
87705(f)(1)
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
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Based on observation, the licensee did not comply with the section cited above as LPAs observed 2 knives on the back patio area, accessible to residents, which poses an immediate safety risk to persons in care.
POC Due Date: 08/04/2022
Plan of Correction
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Items were secured in a locked location during the visit. POC cleared.

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: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2022 10:16 AM - 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,
, CA


FACILITY NAME: GOLDEN YEARS CARE
FACILITY NUMBER: 565800906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(g)
Care of Persons with Dementia
(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in at least 1 of 3 residents are at risk if allowed access to personal grooming and hygiene items and LPAs observed an unlocked cabinet containing personal care items and resident restroom contained accessible shampoos, creams, ointments which poses an immediate safety risk to persons in care.
POC Due Date: 08/04/2022
Plan of Correction
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Items were secured in a locked location during the visit. POC cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2022 10:16 AM - 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,
, CA


FACILITY NAME: GOLDEN YEARS CARE
FACILITY NUMBER: 565800906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as two (2) out of two (2) residents with a diagnosis of dementia did not have an annual medical assessment in the files, which poses a potential health and safety risk to persons in care.
POC Due Date: 08/17/2022
Plan of Correction
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Licensee agreed to obtain an updated medical assessment for the resident by POC due date
Type B
Section Cited
CCR
87611(d)
(d) In addition to Section 87463, Reappraisals and Section 8, Observation of the Resident, the licensee shall monitor the ability of the resident to provide self care for the allowable health condition and document any change in that ability.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 residents with a dementia diagnosis did not have an annual reappraisal which poses a potential health risk to persons in care.
POC Due Date: 08/17/2022
Plan of Correction
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The licensee agreed to complete an annual assessment for the resident by POC 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.
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 4 of 11


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GOLDEN YEARS CARE
FACILITY NUMBER: 565800906
VISIT DATE: 08/03/2022
NARRATIVE
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KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All cleaning supplies were observed to be locked and properly stored at the time of the visit. At 10:20AM, LPA observed the water temperature at 114.1 degrees Fahrenheit.

BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 4 (four) total bedrooms; 2 (two) are currently occupied for resident use, 1 (one) is locked and being used for storage, and 1 (one) was observed locked and designated as a staff room.

RESTROOMS: The LPAs noted there are 2 restrooms in the facility; one is designated for resident use and one is for staff use. LPAs observed the resident restroom. Resident restroom was clean and sanitary and in operating condition with grab bars and non-skid surfaces. At 10:16AM, LPAs observed accessible personal grooming and hygiene items, including shampoo, Aquanet hairspray, ointment, DermaDaily lotion, and toothpaste, on the bathroom counter, accessible to residents in care. At 10:22AM, LPAs observed the water temperature in the resident restroom to be 114.4 degrees Fahrenheit.

RESIDENT FILES: Were reviewed at 10:55AM. At 11:06AM, LPAs observed Resident #1 (R1) has a diagnosis of dementia and has a physician's report dated 09/11/2019; physician's report indicates R1 is "at risk if allowed access to personal grooming and hygiene items." R1's appraisal is dated 10/05/2019. During file review, Resident #2 (R2)'s file was reviewed and did not contain a medical assessment.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPAs observed all visitors to be wearing masks, however staff and residents are not consistently encouraged to wear face coverings in common areas. The LPAs observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. Licensee stated that neither of the 2 regular staff are vaccinated, neither has an exemption on file and both staff are not COVID tested weekly. To date, the facility has not submitted an Infection Control plan.


Report Continued on LIC 809-C
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 9 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GOLDEN YEARS CARE
FACILITY NUMBER: 565800906
VISIT DATE: 08/03/2022
NARRATIVE
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The following recommendations were made:
- N95 fit testing for all staff
- Post PINs and educate staff, residents, and families on changing policies and procedures from the Department
-Staff and residents should be encouraged to wear masks while in common areas
-Facility should have a backup plan for staffing

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided via email.
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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