565801579-8-20-2024-29-AS-VCOY-D8BT5W-20240820142614

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801579
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:26:20 PM

Document Has Been Signed on 08/20/2024 02:26 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 HORIZON		FACILITY NUMBER:	565801579
ADMINISTRATOR:	CHARMIE GUEMO		FACILITY TYPE:	740
ADDRESS:	2221 BRIARFIELD		TELEPHONE:	(805) 388-0308
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 3	DATE:	08/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Charmie Guemo		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:30 A.M. LPA met with Administrator Charmie Hayag and Licensee Maricel Villaverde. Entrance interview conducted. Beginning at 10:45 A.M., the LPA, along with Administrator and Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: This includes the living room, dining room areas and recreation/sitting area. LPA observed common area to be clean and properly furnished at the time of the visit. The LPA observed the fire extinguishers to be fully charged and last serviced on 05/05/2024. Hardwired smoke detectors and separate carbon monoxide detector were tested at 11:52 A.M. and were functional at the time of the visit. Additionally, this facility is equipped with a sprinkler system. Last inspection by the Fire Marshal was conducted on 06/21/2024. The LPA observed the required postings throughout the facility. BEDROOMS: There are four (4) bedrooms in the facility. At the time of the visit, bedrooms #1 and #3 are designated for shared resident use, bedroom #2 is occupied by a single resident and one (1) staff room. The staff room is kept locked. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Continued 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: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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 3

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 HORIZON	FACILITY NUMBER: 565801579
	VISIT DATE: 08/20/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC 809

BATHROOMS: There are two (2) bathrooms for resident use. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters. Toilets were observed to be operable. Hot water temperature was measured in the shared resident bathrooms and measured in compliance with regulation.

KITCHEN: The LPA observed the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Also, amounts of emergency water and food are adequate. The LPA observed one designated cabinet where knives and sharps are stored locked and inaccessible to residents. Cleaning supplies are located in a locked cabinet under the kitchen sink. At 10:52 A.M. hot water temperature measured 114.9 degrees Fahrenheit.

LAUNDRY & GARAGE: The locked laundry room is located adjacent to the kitchen. Laundry supplies and chemicals are stored inaccessible to residents in care. Laundry area also contains an extra freezer, pantry, and emergency food/water supply. Garage was observed locked and contained PPE supplies, cleaning supplies, backup generator, and extra food supply.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. Facility has two total gates; both were observed to be self-latching and closing with clear passageways for emergency exit use. LPA did not observe any obstructions or hazards on hallways, stairways nor exits during the visit. There were no bodies of water on the premises at the time of the visit. A separate locked ADU unit was observed on the property and is used to house an adult family member, who is fingerprint background associated to the facility.

Continued 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: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 HORIZON	FACILITY NUMBER: 565801579
	VISIT DATE: 08/20/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC 809C

RECORD REVIEW: Began at 11:42 A.M. (resident records) and 12:01P.M. (staff records.) 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. All three (3) resident records reviewed were complete and contained all required documents. All five (5) staff files reviewed were also complete and contained all required documents. LPA requested the following documents: staff schedule, resident roster, liability insurance and last emergency drill. Last emergency drill was conducted on June 2024.

MEDICATION REVIEW: Began at 12:35 P.M. Medications for three (3) of three (3) residents were observed. All medications observed were labeled, stored, and properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Medications are stored in a locked closet next to Room #2 and #3. LPA observed two (2), 1^st Aid kit and respective manuals inside locked medication closet.

No deficiencies cited. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3