565801579-8-11-2023-29-AS-KDUK-CUM2MT-20230811173139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801579
Report Date: 08/11/2023
Date Signed: 08/11/2023 05:32:05 PM

Document Has Been Signed on 08/11/2023 05:32 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 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: 5	DATE:	08/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:12 PM
MET WITH:	Maricel Villaverde & Charmie Hayag		TIME COMPLETED:	05:45 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) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 02:12PM. LPA met with Administrator Charmie Hayag. Licensee Maricel Villaverde was contacted via telephone and arrived at the facility at approximately 02:50PM. Entrance interview conducted. Beginning at 02:20PM, the LPA, along with Administrator 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 and dining room areas. 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 06/30/2023. Hardwired smoke detectors and separate carbon monoxide detector were tested at 05:12PM and were functional at the time of the visit. BEDROOMS: There are four (4) bedrooms in the facility; three (3) bedrooms are designated for shared resident use 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. 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 water temperature was measured in the shared resident bathroom and measured in compliance with regulation. KITCHEN: The LPA observed the kitchen/dining area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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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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 HORIZON	FACILITY NUMBER: 565801579
	VISIT DATE: 08/11/2023

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food and emergency water. 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. Water temperature was observed in the kitchen sink and measured within regulation.

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. There were no bodies of water on the premises at the time of the visit.A separate ADU unit was observed on the property and is used to house an adult family member, who is fingerprint background associated to the facility.

RECORD REVIEW: Began at 02:35PM (resident records) and 04:22PM (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 five (5) of five (5) resident records reviewed were complete and contained all required documents. All five (5) of five (5) staff files reviewed were also complete and contained all required documents.

MEDICATION REVIEW: Began at 03:27PM. Medications for five (5) of five (5) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. Emergency disaster drills are conducted quarterly, with the last drill conducted on 08/06/2023. The facility’s policies and procedures as it pertains to infection control are adequate.

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

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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