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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801579
Report Date: 09/17/2025
Date Signed: 09/17/2025 02:55:46 PM

Document Has Been Signed on 09/17/2025 02:55 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOLDEN HORIZONFACILITY NUMBER:
565801579
ADMINISTRATOR/
DIRECTOR:		CHARMIE GUEMOFACILITY TYPE:
740
ADDRESS:2221 BRIARFIELDTELEPHONE:
(805) 388-0308
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 3DATE:
09/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:02 AM
MET WITH:Maricel VillaverdeTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:00 A.M. LPA met with Administrator, Charmie Hayag and Licensee Maricel Villaverde. Entrance interview conducted.

Beginning at 10:15 A.M., the LPA, along with Administrator and Licensee 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. Facility has a fire clearance for six (6) bedridden residents. The following was observed:

COMMON AREAS: This includes the living room, dining room areas and recreation/sitting area. LPA observed common areas to be clean and properly furnished at the time of the visit. The LPA observed activities for resident use in the recreation/sitting area as well as an office area. Office area had a computer desk, a phone available to everyone and residents and staff files. The fireplace was observed adequately screened. The LPA observed the fire extinguisher to be fully charged and last serviced on 04/11/2025. Hardwired smoke detectors and a separate carbon monoxide detector were tested at 10:45 A.M. and were functional at the time of the visit. Additionally, this facility is equipped with a sprinkler system. The last inspection by RLD Fire Protection. Inc wa conducted on 06/12/2025. No concerns noted. The LPA observed the required postings throughout the facility. The facility is equipped with a fire door to enhance safety and prevent the spread of fire. During today’s visit, the fire door was observed closed.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
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 4
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN HORIZON
FACILITY NUMBER: 565801579
VISIT DATE: 09/17/2025
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Continued from LIC 809-C

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for residents’ use. Facility has two total gates; both were observed to be self-latching and closing with clear passageways for emergency exit use. LPA did not observe any obstructions or hazards on hallways nor exits during the visit. There were no bodies of water on the premises at the time of the visit.A separate locked ADU unit was observed on the property and is used to house an adult family member, who has fingerprint clearance and is associated to the facility.

RECORD REVIEW: Began at 12:20 P.M. (resident records) and 12:50 P.M. (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 three (3) resident records reviewed were complete and contained all required documents. All five (5) staff files reviewed were also complete and contained all required documents. LPA requested the following documents: staff schedule, resident roster, liability insurance and last emergency drill. The last emergency drill was conducted on 09/01/2025.

MEDICATION REVIEW: Began at 1:15 P.M. Medications for three (3) of three (3) residents were observed. Medications are stored in a locked hallway closet. All medications observed were labeled, stored, and properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. LPA observed two (2), 1st Aid kit and respective manuals inside locked medication closet.

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

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

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN HORIZON
FACILITY NUMBER: 565801579
VISIT DATE: 09/17/2025
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Continued from LIC 809-C

BEDROOMS: There are four (4) bedrooms in the facility. At the time of the visit, LPA observed one shared room and two (2) single occupancy bedrooms. Also, LPA observed a locked staff room. All residents’ rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

BATHROOMS: There are two (2) bathrooms for residents’ use. Bathrooms were observed to be equipped with slip-resistant surfaces and contain slip-resistant mats. Grab bars were observed in the bathrooms. The LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters. Toilets were observed to be operable. The hot water temperature in all bathrooms was tested and initially measured below 105 degrees Fahrenheit. The water heater temperature was adjusted at that time. LPA subsequently retested the hot water in all bathrooms, and the temperatures were found to be within the regulatory range.

KITCHEN: The LPA observed the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Also, emergency water and food are adequate. 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. At 10:22 A.M. hot water temperature measured 109.7 degrees Fahrenheit.

LAUNDRY & GARAGE/STORAGE: 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 converted into a storage room. Storage room was locked at the time of the visit and contained a small break room for employees, extra PPE supplies, cleaning supplies, backup generator, and extra food supply.


Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4