565800906-8-6-2024-29-AS-VCOY-D7VV47-20240806160551

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800906
Report Date: 08/06/2024
Date Signed: 08/06/2024 04:05:57 PM

Document Has Been Signed on 08/06/2024 04:05 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GOLDEN YEARS CARE		FACILITY NUMBER:	565800906
ADMINISTRATOR:	LARRY WAYNE		FACILITY TYPE:	740
ADDRESS:	1325 LANTANA STREET		TELEPHONE:	(805) 383-1188
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 1	DATE:	08/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:			TIME COMPLETED:	02:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:15 A.M. The LPA met with Licensees Teresita and Larry Wayne and discussed the reason for the visit. At the time of the visit facility facility has only one (1) resident.

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 10:37 A.M. 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.

Continues on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN YEARS CARE	FACILITY NUMBER: 565800906
	VISIT DATE: 08/06/2024

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Continued from LIC 809

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 the time of the visit. At 9:30 A.M. hot water measured at 114.9 degrees Fahrenheit.

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; 1 (one) are currently occupied for resident use, 1 (one) is locked and being used for storage, and 3 (three) 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 hot water temperature in the resident restroom to be 117.1 degrees Fahrenheit.

RECORD REVIEW: Beginning at 11:00 A.M., 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. 1 (one) resident record reviewed was complete and contained all required documents. Last emergency drill was conducted on July 2024. 2 (two) of 2 (two) staff files reviewed did not contain proof of CPR or first aid.

MEDICATION REVIEW: Beginning at 11:20 A.M., LPA reviewed medications for 1 (one) resident. Prescription medications were observed to be maintained and administered in compliance with regulation. The facility is using the centrally stored medication records.

INTERVIEWS: During today's visit facility didn’t have a caregiver to interview and the only resident was in their room sleeping.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies and civil penalties were cited (refer to LIC 809-D).

Exit interview conducted. A hard copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/06/2024 04:05 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN YEARS CARE	FACILITY NUMBER: 565800906
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by 2 (two) out of two (2) staff members had expired CPI/First Aid training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2024
	Plan of Correction
1 2 3 4	Administrator agrees to submit a copy of their renewed CPR/First Aid certificate before POC 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.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

LIC809 (FAS) - (06/04)

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