565801648-7-7-2022-29-AS-MARO-CG4UC2-20220707152715

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801648
Report Date: 07/07/2022
Date Signed: 07/07/2022 03:28:23 PM

Document Has Been Signed on 07/07/2022 03:28 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 LIFE ASSISTED LIVING LLC		FACILITY NUMBER:	565801648
ADMINISTRATOR:	MARIA ROSARIO E. TANGLAO		FACILITY TYPE:	740
ADDRESS:	555 CALLE TULIPAN		TELEPHONE:	(805) 492-8138
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 4	DATE:	07/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Maria Tanglao / Patricia Tanglao		TIME COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required 1-year annual inspection today at 1:00 p.m. The last annual conducted was on 6/06/2019. Upon arriving at the facility, the LPA was scanned and greeted at the door by staff, Patricia Tanglao. The Administrator, Maria Tanglao arrived shortly after and was explained the reason for the visit. Entrance interview conducted.

At 1:15 p.m., the LPA began the physical plant tour with both the Administrator and staff of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed all knives and sharps in a locked box inside a drawer inaccessible to residents. At 1:31 p.m., the LPA observed a medicine box in the refrigerator with the key inserted in the lock making medicine accessible to residents in care.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels for resident use. Bathrooms were measured for hot water, the first bathroom measured at 107.6 degrees Fahrenheit at 1:20 p.m., the second bathroom measured at 110.7 degrees Fahrenheit at 1:24 p.m., and the third bathroom was measured at 113.7 degrees Fahrenheit at 1:28 p.m.

…Continued on LIC 809C…

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

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 LIFE ASSISTED LIVING LLC	FACILITY NUMBER: 565801648
	VISIT DATE: 07/07/2022

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…Continued from LIC 809...

GARAGE AND GROUNDS: The garage is attached to the house and locked at all times. There is one (1) additional freezer in the garage with perishable items in good condition. Toxins and cleaning supplies were observed locked in a cabinet in the garage at the time of visit. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Facility has an adequate amount of emergency food and emergency water. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. No large bodies of water accessible to residents at the time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The facility is maintained at 76 degrees Fahrenheit. Fire extinguisher was observed and last serviced on June 2022. The LPA observed four (4) residents in the green room watching television during time of visit. Medications are locked in a closet by the hallway.

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, symptoms of COVID-19, and CDSS PINS pertaining to visitation guidelines. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA and Administrator discussed staff vaccination requirements. All staff and residents are fully vaccinated. Staff were observed wearing face coverings during time of visit. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

Pursuant to Title 22, California Code of Regulations, the following deficiencies will be cited (refer to LIC 9099-D)

Exit interview conducted. Appeal Rights discussed. A copy of this report was sent via email to Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/07/2022 03:28 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 LIFE ASSISTED LIVING LLC	FACILITY NUMBER: 565801648
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87464(h)(2)

87465(h)(2) Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above as the medicine box in the refrigerator had the key inside the lock at the time of visit, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/07/2022
	Plan of Correction
1 2 3 4	Administrator locked and removed key from lock at the time of visit. Administrator stated that she will conduct staff training regarding regulation 87465 (h)(2) and will provide documentation of training to CCL by 7/08/2022.

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: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC809 (FAS) - (06/04)

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