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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800906
Report Date: 07/26/2023
Date Signed: 07/26/2023 06:39:25 PM


Document Has Been Signed on 07/26/2023 06:39 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



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:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Larry WayneTIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:15PM. The LPA met with Licensees Teresita and Larry Wayne and discussed the reason for the visit.

The LPA, 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:

Fire extinguishers were observed to be fully charged, but purchased over 12 months prior to today's visit. During the visit, Licensee purchased new fire extinguishers. Hardwired smoke detectors and separate carbon monoxide detector were tested at 06:10PM and were functional at the time of the visit.

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 LPA observed the required postings in the common area.

The backyard has a covered outdoor area equipped with furniture for resident use. Licensee indicated the residents do not use the backyard area. There were no bodies of water noted. The back patio did contain items being stored, however no hazardous items were observed and the passageways were clear from obstructions.

The laundry room was observed to be locked and contained cleaning chemical storage, as well as storage for additional items. The garage was observed locked.



KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All sharp objects were observed to be locked and properly stored at Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN YEARS CARE
FACILITY NUMBER: 565800906
VISIT DATE: 07/26/2023
NARRATIVE
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the time of the visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 2 (two) are currently occupied for resident use, 1 (one) is locked and being used for storage, and 2 (two) were observed locked and designated as staff rooms.

RESTROOMS: The LPA noted there are 2 restrooms in the facility; one is designated for resident use and one is for staff use. LPA observed the resident restroom. Resident restroom was clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed the water temperature in the resident restroom to be 112.1 degrees Fahrenheit.

RECORD REVIEW: Beginning at 12:40PM, staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 3 (three) of 3 (three) resident records reviewed were complete and contained all required documents. 2 (two) of 2 (two) staff files reviewed did not contain proof of CPR or first aid.



MEDICATION REVIEW: Beginning at 05:19PM, LPA reviewed medications for 3 (three) of 3 (three) residents. The facility does not currently have centrally stored medication records, although all 3 (three) residents have medications the facility is storing and assisting in administering.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA spoke with the Licensee regarding the facility's Emergency Disaster plan and Infection Control Plan. To date, the facility has not submitted an Infection Control plan. LPA provided both the infection control plan template and the Emergency and Disaster plan template to the Licensee via email.

INTERVIEWS: During today's visit, LPA interviewed facility staff and attempted to interview residents.

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.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/26/2023 06:39 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: GOLDEN YEARS CARE
FACILITY NUMBER: 565800906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
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
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Based on record review, the licensee did not comply with the section cited above as neither of the 2 (two) staff employed at the facility do not have current CPR or first aid training which poses a potential health and safety rights risk to persons in care.
POC Due Date: 08/09/2023
Plan of Correction
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Licensee agreed to obtain first aid and CPR training for both staff and submit proof of completed training to CCL by POC due date.
Type B
Section Cited
CCR
87465(a)(6)
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
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Based on observation and record review, the licensee did not comply with the section cited above as 3 residents have centrally stored medications, however there is no centrally stored medication record for any of the 3 residents which poses a potential health risk to residents in care.
POC Due Date: 08/09/2023
Plan of Correction
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Licensee agreed to complete the centrally stored medication record for the 3 residents and submit proof to CCL 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 07/26/2023 06:39 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: GOLDEN YEARS CARE
FACILITY NUMBER: 565800906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)(1)

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as the facility does not have an infection control plan which poses a potential health and safety rights risk to persons in care.
POC Due Date: 08/09/2023
Plan of Correction
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Licensee agreed to develop and complete an infection control plan and submit the plan to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6