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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800906
Report Date: 06/16/2021
Date Signed: 06/16/2021 01:34:06 PM

Document Has Been Signed on 06/16/2021 01:34 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 YEARS CAREFACILITY NUMBER:
565800906
ADMINISTRATOR:LARRY WAYNEFACILITY TYPE:
740
ADDRESS:1325 LANTANA STREETTELEPHONE:
(805) 383-1188
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 4DATE:
06/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Larry WayneTIME COMPLETED:
01:30 PM
NARRATIVE
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This Case management visit was conducted to address the deficiencies noted during complaint control # 29-AS-20210610110654 investigation visit conducted on 6/16/21.

During facility tour on 6/16/21 starting at 11:18 PM LPA's observed hedge trimmer, chain saw and weed wacker in backyard accessible to residents. At 11:21 AM, LPA's observed wound cleaner and Lysol disinfectant spray in dinning room area accessible to residents. At 11:24 AM, LPA's observed Lysol disinfectant spray and Febreze odor spray in a restroom accessible to residents.


Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted, todays reports reviewed and email to administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2021
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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Document Has Been Signed on 06/16/2021 01:34 PM - It Cannot Be Edited


Created By: Angel Ascencio On 06/16/2021 at 12:13 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOLDEN YEARS CARE
FACILITY NUMBER: 565800906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2021
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by
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Staff placed items in an inaccessible location during facility visit. Administrator stated that he will provide documentation of scheduled staff training with outside agency regarding regulation 87705(f)(2).
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Based on LPA's observations, the licensee did not comply with the section cited above as toxic substances were observed throughout the facility accessible to residents which posed an immediate health risk to persons in care.
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Type A
06/17/2021
Section Cited
CCR87705(f)(1)

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87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Staff placed items in an inaccessible location during facility visit. Administrator stated that he will provide documentation of scheduled staff training with outside agency regarding regulation 87705(f)(1).
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Based on LPA's observations, the licensee did not comply with the section cited above as hedge trimmer, chain saw and a weed wacker was observed accessible to residents which posed an immediate health and safety risk to persons in care.
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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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021


LIC809 (FAS) - (06/04)
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