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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801648
Report Date: 07/08/2025
Date Signed: 07/08/2025 02:43:01 PM

Document Has Been Signed on 07/08/2025 02:43 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 LIFE ASSISTED LIVING LLCFACILITY NUMBER:
565801648
ADMINISTRATOR/
DIRECTOR:		MARIA ROSARIO E. TANGLAOFACILITY TYPE:
740
ADDRESS:555 CALLE TULIPANTELEPHONE:
(805) 492-8138
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
07/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Maria R.E. Tanglao - AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10 a.m. Upon arrival, LPA Mosley was greeted by staff and the Administrator and informed them of the visit. LPA met with Administrator, Maria R.E. Tanglao and the reason for the visit was explained. Entrance interview. The LPA 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.

COMMON AREAS: The facility is a single-story structure with a large sun room, dining room and living room. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 12:50 p.m., hardwire combination of smoke / carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 07/18/2024 and scheduled for service on 07/10/2025. The emergency telephone numbers are posted in common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 06/01/2025 and are conducted monthly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. LPA did not observe any obstructions or hazards.

KITCHEN: The LPA inspected the kitchen/food service area at 10:14 a.m. Knives and sharps were observed in a locked lock box in a bottom drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 119.4 degrees Fahrenheit at 10:15 a.m.

REPORT CONTINUED ON LIC 809-C PAGE 2...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 9
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 LIFE ASSISTED LIVING LLC
FACILITY NUMBER: 565801648
VISIT DATE: 07/08/2025
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(PAGE 2) REPORT CONTINUED FROM LIC 809...
INTERVIEWS: Starting at 10:37 a.m. one (1) staff and five (5) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit.

BEDROOMS: There are five (5) total bedrooms in the facility; all bedrooms are designated as private, single occupancy, resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. No staff room. Licensee provided proof of 24 hour staffing.

RESTROOMS: There are two in a half (2.5) restrooms. One in a half (1.5) are designated as shared / common restrooms and one (1) is designated as a private resident restroom. Resident restrooms were observed to be equipped with a nonslip surface. Grab bars were observed in the bathrooms. The restrooms were sufficiently stocked with supplies and paper towels. The water temperature was measured all resident restrooms and ranged between 113.9-114.1 degrees Fahrenheit, all within the required range.

OUTDOOR SPACE: The LPA observed the back yard which had a shaded patio area with patio furniture including a table and chairs for resident use. The LPA observed one gate that self-latches with a clear passageway in case of an emergency. There are no bodies of water on the premises at the time of the visit. LPA observed a locked storage unit with supplies and outdoor equipment that remains locked at at all time.

GARAGE: The garage is not accessible to residents. Laundry units, cleaning solutions, toxins, chemicals, and hazardous items are kept in the locked laundry room/ garage. There was a linen cabinet in the garage with extra towels and linens. Administrator's office is also set up in the garage. The garage is kept locked and inaccessible.

RECORDS: Record review began at approx. 10:50 am. Resident Records were reviewed beginning at 10:50 a.m. and Personnel Records at 11:50 a.m. Five (5) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Four (4) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

REPORT CONTINUED ON LIC 809-C PAGE 3...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
Page: 8 of 9
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 LIFE ASSISTED LIVING LLC
FACILITY NUMBER: 565801648
VISIT DATE: 07/08/2025
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(PAGE 3) REPORT CONTINUED FROM LIC 809 PAGE 2...

Infection Control / Emergency disaster planning: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control and emergency planning are satisfactory.



MEDICATIONS: Medications review began at approximately 2:15 p.m. The medications are in a locked medication closet adjacent to the kitchen. Medications for four (4) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review.

LPA obtained the following documents - Resident roster - LIC 9020, Staff roster - LIC 500, and a copy of the Limited Liability insurance.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of the report provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
Page: 9 of 9