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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209341
Report Date: 08/15/2024
Date Signed: 08/20/2024 10:27:02 AM

Document Has Been Signed on 08/20/2024 10:27 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:GOLDRIDGE HOME LLCFACILITY NUMBER:
107209341
ADMINISTRATOR/
DIRECTOR:		RIEMER, ROSEMARIE H.FACILITY TYPE:
740
ADDRESS:2145 GOLDRIDGE STTELEPHONE:
(559) 317-7442
CITY:SELMASTATE: CAZIP CODE:
93662
CAPACITY: 6CENSUS: 6DATE:
08/15/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Licensee/Administrator Rosemarie Riemer TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 08/15/24, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct a continuation of the Required Annual Inspection. LPA met with staff Teopista “Fay” Gasapos. Licensee/ Administrator Rosemarie Riemer was called and arrived later during inspection.

All staff files were reviewed. Staff working on shift during inspection did not have current CPR


certification.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22,


Division 6.

An exit interview was conducted. Plan of correction was discussed with Licensee/ Administrator. The following documents are requested and submitted to Fresno CCL by: 8/21/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability insurance, and current Administrator Certificate. A copy of this report and appeal rights was provided to Licensee/Administrator, whose signature on this form confirms receipt of these report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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
Document Has Been Signed on 08/20/2024 10:27 AM - It Cannot Be Edited


Created By: Mai Yang On 08/15/2024 at 02:34 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GOLDRIDGE HOME LLC
FACILITY NUMBER: 107209341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
1569.618 (c)(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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All staff files were reviewed, and interviews conducted, S1 the only staff working on shift do not have current First Aid/ CPR certification, this poses an immediately health and safety risk for the residents in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee shall ensure that staff have current First Aid/ CPR certification. Proof of staff First Aid/ CPR certification is to be submitted to the Fresno CCL by 08/16/24.
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.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2024 10:27 AM - It Cannot Be Edited


Created By: Mai Yang On 08/15/2024 at 02:36 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GOLDRIDGE HOME LLC
FACILITY NUMBER: 107209341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1796.45(a)
1796.45 Health and Safety Code 1796.45 TB Testing (a) Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA reviewed all staff files. All staff did not have a TB result on file which poses a potential risk to the health and safety of the residents.
POC Due Date: 09/04/2024
Plan of Correction
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Licensee shall ensure all staff have a TB result on file. Proof of TB results for all staff shall be submitted to the Fresno CCL office by POC due date 09/04/24.
Type B
Section Cited
CCR
87412(a)(11)
87412(a)(11) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA reviewed all staff files. Three out of four staff do not have health screening on file which poses a potential risk to the health and safety of the residents.
POC Due Date: 09/04/2024
Plan of Correction
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Licensee shall ensure all staff good health screening completed. Proof of good health screening for all staff shall be submitted to the Fresno CCL office by POC due date 09/04/24.
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:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/20/2024 10:27 AM - It Cannot Be Edited


Created By: Mai Yang On 08/15/2024 at 02:37 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GOLDRIDGE HOME LLC
FACILITY NUMBER: 107209341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(c)
87412(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed and interviews, facility do not record any of the staff trainings. No documentation of staff trainings are documented and on file which poses a potential health and safety risk for the person in care.
POC Due Date: 09/11/2024
Plan of Correction
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Facility shall review regulation section 87412 and ensure that all staff have the required training. Proof of trainings is to be submitted to the Fresno CCL office by the POC due date 09/11/24.

Proof of training shall include the following: Trainer’s full name; Subject(s) covered in the training; Date(s) of attendance; and Number of training hours per subject.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
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