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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801327
Report Date: 02/08/2023
Date Signed: 02/08/2023 04:44:48 PM


Document Has Been Signed on 02/08/2023 04:44 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 ACRES RCFE IIFACILITY NUMBER:
565801327
ADMINISTRATOR:BABY JANE ANGELESFACILITY TYPE:
740
ADDRESS:1673 WILLOWBROOK LANETELEPHONE:
(805) 813-6411
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:5CENSUS: 4DATE:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Glenn Magpayo, StaffTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Required - 1 Year inspection at the facility today. At approximately 4:00pm LPA met with staff and explained the reason for the inspection. LPA spoke with administrator Jane Angeles who stated to LPA that she is currently with her mother and will be going to the hospital. Ms. Angeles was informed that today's visit has an emphasis on infection control practices and procedures. Ms. Angeles stated that staff will assist LPA during today's visit.

The LPA, along with staff, toured the physical plant areas inside and outside beginning at 4:15pm to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

COMMON SPACES: The common areas were observed. The fire extinguisher observed full charged. The smoke alarms and carbon monoxide detectors were tested/observed operational. The facility has a sufficient supply of perishable and non-perishable food. There is outdoor seating in the backyard for resident visitation use. Cleaning supplies are secured in the locked garage. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: There are two resident bathrooms. Bathrooms observed with liquid soap, paper towels, and signs regarding proper hand washing.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. There is one (1) entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The LPA observed supply of Personal Protective Equipment (PPE) in the facility and garage. The facility’s cleaning protocol explained 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.

No deficiency observed during todays visit.


Exit interview conducted. A copy of the report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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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