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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610451
Report Date: 07/24/2025
Date Signed: 07/24/2025 03:39:53 PM

Document Has Been Signed on 07/24/2025 03:39 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:1ST GOLDEN SENIOR CARE HOMEFACILITY NUMBER:
197610451
ADMINISTRATOR/
DIRECTOR:		MERLY DEEFACILITY TYPE:
740
ADDRESS:1117 ERWIN DRIVETELEPHONE:
(661) 992-1697
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 5DATE:
07/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Robelyn Geraldino and Sidora GeraldinoTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit on 7/24/2025 and was greeted by two staff members. LPA stated the purpose of the facility was to conduct an annual inspection. Staff confirmed there are five residents living at the facility. The facility is licensed for six non-ambulatory residents.

LPA and the caregiver toured the facility at 10:45 am until 11:15 am.

Common Areas/Dining Room – LPA observed the living room contained comfortable seating along with a television. The dining room area contained a dining room table and chairs.

Kitchen – LPA observed the kitchen was neat and clean. The knives were securely locked in a kitchen drawer. The facility contained a two day supply of perishable food and a seven day supply of non-perishable food items. A fire extinguisher is also located in the kitchen. LPA observed the cleaning solutions were stored in an unlocked cabinet.

Resident Bedrooms - There are five bedrooms. LPA Spaeth observed two mattresses were on the floor and there was no bed frame in bedroom 2. Bedrooms 1, 3, 4 & 5 are furnished with a bed, linens, night stand, chest of drawers and a closet.

Hallway Closets – LPA observed a kitchen closet which contained medications and a first aid kit. A hallway closet contained linens.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: 1ST GOLDEN SENIOR CARE HOME
FACILITY NUMBER: 197610451
VISIT DATE: 07/24/2025
NARRATIVE
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Bathrooms - LPA observed the three bathrooms contained hand soap, paper towels, grab bars, and slip resistant mat. LPA tested the water temperature at 10:55 am, which was 105.0 degrees F.

Laundry Room – LPA observed the room was locked and contained a washer and dryer.

Smoke/Carbon Monoxide Detectors – The detectors were tested at 11:15 am and were operable.

Backyard - LPA observed the backyard which has a shaded area with seating.

Garage - LPA observed the garage was locked. The laundry detergent, cleaning solutions, and emergency water and food were located in the garage.

Delayed Egress Devices - LPA observed delayed egress devices on all exit doors and all devices were properly working.

Storage Buildings - There are one storage building in the backyard which was locked and contained tools.

LPA reviewed client records at 12:00 pm until 12:15 pm LPA reviewed staff records at 12:15 pm until 12:40 pm. LPA reviewed the residents’ medications at 1:00 pm. LPA Spaeth reviewed the resident's medications at 2:15 pm until 2:30 pm.

Pursuant to Title 22, California Code of Regulations, deficiencies will be cited (refer to LIC 809-D.

Exit interview conducted, appeal rights discussed, and a copy of the report was given.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/24/2025 03:39 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 07/24/2025 at 01:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: 1ST GOLDEN SENIOR CARE HOME
FACILITY NUMBER: 197610451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed cleaning solutions were not locked in a cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2025
Plan of Correction
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During LPA's visit, the staff member locked the kitchen cabinet.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2025 03:39 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 07/24/2025 at 01:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: 1ST GOLDEN SENIOR CARE HOME
FACILITY NUMBER: 197610451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(A)
Personal Accommodations and Services
(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed Resident Room #2 was missing the bed frame which could pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2025
Plan of Correction
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To ensure the resident has been provided safe, healthful and comfortable accommodations, the Administrator will provide a bed frame for Resident Room #2.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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