Golden Years Care Home II

Type of visit: Required - 1 Year

On 7/21/2026, at 2:15 PM Licensing Program Analysts (LPAs) Reza Jamaly arrived unannounced at the facility to conduct the required annual inspection. LPAs met with staff on duty who assisted LPA touring the facility then administrator Grace Bernardino joined the meeting. Administrator certificate expires on 9/12/2027. Facility is cleared for 6 residents and census was 6. Firstly, LPA Jamaly inspected the physical plant including but not limited to the common area, kitchen, dining area, 6 resident's bedrooms, resident bathrooms, and outside courtyard of the facility to ensure compliance with Title 22 regulations. LPAs inspected the kitchen and observed a sufficient supply of at least a seven-day supply of nonperishable food and a two-day supply of perishable food. Sharp knives were secured in a locked kitchen cabinet and inaccessible to resident. LPA checked two refrigerator and freezer, one located in kitchen and another outside in front of living room. LPA inspected 6 resident's bedrooms and observed bedrooms to be properly furnished with appropriate bedding and lighting. Resident's bathrooms observed to be cleaned, grab bars and non-slip mats were observed to be secure and in good condition. The hot water temperature measured 108.8 at one of the resident bathroom sink, which is within the required range of 105°F to 120°F. Facility temperature was checked at living room and observed to be 76 degree F. There are no bodies of water present. Continue in LIC 809C in page 2 Smoke detectors and carbon monoxide detectors were observed at hallways and living rooms. Two fire extinguishers, located in living room and in kitchen, was last serviced on 11/04/2026. Last fire drill conducted on 6/16/2026. LPA observed that the facility maintained a public telephone in the kitchen and that all required licensing posters were properly displayed Cleaning supplies and other toxic substances were observed in a cabinet in the laundry room, inaccessible to resident and administrator unlocked garage's door for LPA inspection. Medication were observed to be stored in a locked cabinet in the kitchen and inaccessible to residents. LPA reviewed 3 of 6 residents' centrally stored medication record and MAR which were complete and consistent with physician's orders. The first aid kit was inspected and contained all required supplies. LPA requested resident and staff records for review. LPA reviewed 3 out 6 resident's file and found them to be complete. Two (2) staff files were reviewed and found to be complete. A review of personnel records confirmed that all staff members and other individuals required to undergo caregiver background checks had received criminal record clearances and were properly associated with the facility. The following documents were requested and will be emailed to the LPA by 7/16/2026 no later than 5:00 PM. LIC 308 – Designation of Administrative Responsibility Copy of the Administrator Certificate LIC 610 – Emergency Disaster Plan Proof of Current Liability Insurance LIC 500 – Personnel Report LIC 309 – Administrative Organization Based on today's inspection, the facility was found to be in compliance with applicable Title 22 regulations. An exit interview was conducted with Grace Bernardino , and a copy of the LIC 809 Report was provided to the facility representative.the state’s words, verbatim · CDSS document, Jul 21, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Sommer Hayes and Arvin Villanueva conducted an unannounced Case Management- Annual Continuation visit today, 5/9/2025, a continuation of the Annual visit initiated on 5/8/2025. LPAs initially met with staff on duty and stated the purpose of the visit. The Administrator, Grace Bernardino was notified of the visit and arrived shortly after. The LPAs continued with facility visit to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. LPAs conducted medication review for 2 residents in care. LPAs conducted reviews of 3 resident records and 2 staff records. Per review, facility conducts quarterly fire drills. The last drill was 03/10/25. LPAs requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Facility Responsibility and liability insurance. LPAs provided the following advisories to the Administrator: -Fence repair of the right side in the backyard. -PRN authorization letter for all residents. -Wheelchair blocking exit in Room #1. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed based on this annual visit. Exit interview was conducted and a copy of the report was provided upon exit.the state’s words, verbatim · CDSS document, May 9, 2025

Type of visit: Required - 1 Year

An unannounced Annual visit was made by Licensing Program Analysts (LPAs) Sommer Hayes and Arvin Villanueva to this facility on 05/08/25 for an annual inspection. LPAs identified themselves upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPAs met with Administrator, Grace Bernadino and a brief interview followed. LPAs toured the facility with Administrator, Grace Bernardino and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 78 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 102.7 degrees Fahrenheit in 1 of 3 bathrooms. LPAs observed 4 residents present. LPAs observed first aid supplies, the carbon monoxide/smoke detectors, the fire extinguisher was last serviced on 11/21/24 by Jorgensen and was in compliance at the time of inspection. LPAs observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPAs observed a locked cabinet for the storage of medication. LPAs observed an inaccessible locked cabinets for the storage of knives. Due to time constraints this Annual will need a continuation visit. The Department will return at a later date. An exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 8, 2025

Allegation investigated: Staff did not ensure that facility was kept free of infestation

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to investigate the above mentioned allegations on 7/10/24 at 11:00a. LPA met with Administrator Grace Bernardino and stated the purpose of the visit. LPA conducted a tour of the facility, resident rooms, and furniture. LPA conducted interviews of residents, staff and Administrator during this visit. Regarding allegation, "Staff did not ensure that facility was kept free of infestation", LPA observed food items in the drawers with roaches in room 6 during this visit. LPA also observed blue powder along the floor boards of the bathroom that Licensee is using to rid the facility of any pests. During visit, Administrator assisted resident with putting opened food items in a zip lock bag. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. Appeal rights were provided. An exit interview was conducted, and a copy of the report was provided. Substantiatedthe state’s words, verbatim · CDSS document, Jul 10, 2024 · control 27-AS-20240708104744

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(27) · Plan of correction due date: Jul 19, 2024

General Food Service Requirements All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on LPAs observations of opened food items and roaches in chester of drawers in room 6. This violation poses an potential health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 10, 2024

Plan of correction: Licensee/Administrator shall contact a pest control company to treat the facility for roaches. Set date shall be faxed to CCL by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 3/22/24 at 11:30am. LPA observed the Administrator Certificate expired on 8/12/23. LPA observed the pending list with Department of Social Services (CCL) and it has not been received yet. LPA met with Grace Bernardino, Administrator and stated the purpose of todays visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which 2 may receive hospice care services. There is 1 residents receiving hospice care services during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. Disaster drill last conducted on 12/10/23. The temperature inside the facility was observed to be at 72*F which is within the required range of 68-85*F. The hot water temperature was measured at 106.0*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 1 staff and 2 resident files and conducted interviews during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Current Criminal Record Clearances LIS536-Current Administrative Organization LIC309-Current Designation of Administrative Responsibility LIC308-Submit Personnel Report LIC500-Submit Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Facility Floor Plan/Plot Plan LIC999-Current Fire Clearance (consistent with terms and limitations of license)-NA Qualifications of Administrator/Facility Manager-Submit Articles of Incorporation/Organization, Constitution and bylaws-NA Partnership Agreement-NA Control of Property-Submit Emergency Disaster Plan LIC610-Submit Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-NA Health Screening Report-Facility Personnel LIC503-NA Bacteriological Analysis of Private Water Supply-NA In-service Training Program-NA Medication Procedures-NA Transportation Procedures-NA Job Description/Personnel Policies-NA Exemptions/Waivers and Exceptions-Current First aid/CPR certificates-Current Liability Insurance-Submit Infection Control Plan-Submit Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.the state’s words, verbatim · CDSS document, Mar 22, 2024

Allegation investigated: Staff do not ensure that resident's needs are met Staff do not keep the facility free of cockroaches Staff are not able to communicate with residents Staff mismanaged resident's medication

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to investigate the above mentioned allegations on 3/8/24 at 1:45p. LPA met with Administrator Grace Bernardino and stated the purpose of the visit. LPA conducted a tour of the facility, resident rooms, and furniture. LPA obtained a copy of the staffing schedule for March 2024. LPA conducted interviews of residents, staff and Administrator during this visit. R1 - R3, S1-S2, and Administrator stated there is always staff available when needed during day and night. LPA did not observe roaches in the facility. LPA observed food items in the bed, table(s) and closet of R1 but did not observe any insects or droppings. LPA observed the product Ortho Home Defense that the Administrator is using to avoid insects in the home. Unfounded R1 - R3, S1-S2, and Administrator stated the staff communicates in English to them all the time. R1 - R3, S1-S2, and Administrator stated there has not been any medication errors. LPA observed the MARs during this visit. The investigation revealed that the allegations mentioned above are unfounded at this time. "The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint." Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided.the state’s words, verbatim · CDSS document, Mar 8, 2024 · control 27-AS-20240307160247