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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800906
Report Date: 08/13/2025
Date Signed: 08/14/2025 06:55:46 AM

Document Has Been Signed on 08/14/2025 06:55 AM - 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 YEARS CAREFACILITY NUMBER:
565800906
ADMINISTRATOR/
DIRECTOR:		LARRY WAYNEFACILITY TYPE:
740
ADDRESS:1325 LANTANA STREETTELEPHONE:
(805) 383-1188
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 1DATE:
08/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Larry WayneTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
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Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 11:17 A.M. The LPAs met with Licensees Teresita and Larry Wayne and discussed the reason for the visit. At the time of the visit the facility has only one (1) resident. The administrator stated that they intend to close the facility and are seeking to have Resident #1 (R1) relocated.

The LPA, along with facility Licensee Larry Wayne, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers were observed to be fully charged but purchased on 08/06/2024. At 1:25 P.M. hardwired smoke detectors and a separate carbon monoxide detector were tested and were functional at the time of the visit.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, the living room and dining room furniture was observed to be in good condition. The LPAs observed the required postings in the common area. The backyard was observed to be cluttered with multiple objects blocking emergency exit, however, the licensee stated that R1 does not utilize that area. There were no bodies of water noted. The garage was observed locked and is also used as a storage room.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2025
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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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.

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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN YEARS CARE
FACILITY NUMBER: 565800906
VISIT DATE: 08/13/2025
NARRATIVE
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Continued LIC 809

KITCHEN: Kitchen appliances appeared to be in operable conditions. The facility has a sufficient supply of perishable, non-perishable food, emergency water and emergency food. All sharp objects were observed to be locked and properly stored at the time of the visit. At 1:25 P.M. hot water measured at 114.9 degrees Fahrenheit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 1 (one) is currently occupied for resident use, three (3) were being used for storage, and one (1) was designated as a staff room.

RESTROOMS: The LPAs noted there are 2 restrooms in the facility; one is designated for resident use, and one is for staff use. LPAs observed the resident restroom. The resident restroom was clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. At 1:28 P.M. hot water measured 113.9 degrees Fahrenheit.

RECORD REVIEW: Beginning at 12:40 P.M., 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. Review of R1’s record revealed missing required documentation, including a needs and service plan, physician’s report, consent forms and face ID sheet. Review of two administrators’ files showed that both administrators’ certificates were expired at the time of the visit. Last emergency drill was not documented. Liability insurance is expired. The last Emergency Plan and Infection Control Plan were not provided (Technical Violation issued).

MEDICATION REVIEW: Beginning at 1:32 P.M., LPA Dulek reviewed medications for R1. Prescription medications appeared to be maintained and administered in compliance with regulation. The facility is using the centrally stored medication records, however, did not have August medications documented.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN YEARS CARE
FACILITY NUMBER: 565800906
VISIT DATE: 08/13/2025
NARRATIVE
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Continued from LIC 809-C

INTERVIEWS: During today's visit LPAs interviewed R1. The facility does not have a caregiver to interview only the administrators who were interviewed.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies and civil penalties were cited (refer to LIC 809-D).

Exit interview conducted. A hard copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 06:55 AM - It Cannot Be Edited


Created By: Valeria Conway On 08/13/2025 at 06:00 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: 08/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having obstacles blocking emergency exit on bedroom #4, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2025
Plan of Correction
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Administrator stated that facility will close soon and they are working on relocating R1. Administrator agreed to remove all objects obstructing the path on room #4 and side gate.
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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 06:55 AM - It Cannot Be Edited


Created By: Valeria Conway On 08/13/2025 at 06:00 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: 08/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a valid liability insurance on record which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2025
Plan of Correction
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Administrator stated that facility will close and insurance won't be renewed. If facility is not closed in 60 days LPA expects liability insurance to be renewed.
Type B
Section Cited
CCR
87406(a)
Administrator Certification Requirements
(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having both administrator certificates expired which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2025
Plan of Correction
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The administrator stated that the facility will close, and the certificate won't be renewed. If the facility is not closed in 60 days the LPA expects administrator certificate to be renewed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 06:55 AM - It Cannot Be Edited


Created By: Valeria Conway On 08/13/2025 at 06:00 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: 08/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current required documentation for R1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2025
Plan of Correction
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Administrator agreed to have at least a new physician's report conducted to help relocate R1 due to facility closure.
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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2025


LIC809 (FAS) - (06/04)
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