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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201730
Report Date: 02/24/2026
Date Signed: 02/24/2026 03:02:44 PM

Document Has Been Signed on 02/24/2026 03:02 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:GOLDEN VILLA HOMEFACILITY NUMBER:
157201730
ADMINISTRATOR/
DIRECTOR:		SILVA, WENDYFACILITY TYPE:
740
ADDRESS:4420 FOXBORO AVETELEPHONE:
(661) 564-8574
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
02/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Administrator Joan AquinoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 02/24/2026, Licensing Program Analyst (LPA) J.Duarte arrived unannounced to conduct an annual inspection. LPA knocked at the door and there was no answer. LPA contacted Administrator Wendy Silva and she stated that Joan Aquino will be reporting to the facility for this annual inspection. Shortly after Administrator Joan Aquino and caregiver Glen Dia arrived. LPA introduced self, stated the purpose of the visit, and was granted entry. Administrator Aquino reported that all four residents were at day program.

LPA toured the facility with the administrator. The facility was observed to be at 69 degrees F, clean, in good repair, and no passageway obstructions were observed. The common areas were well lit with adequate seating for residents. The facility had a two-day supply of perishable and seven-day supply of non-perishable food. Chemicals and sharps were observed locked in kitchen cabinets.

Medications and the first aid kit were observed in a locked hallway closet. The hallway restroom hot water measured at 109 degrees F. The restroom hot water attached to the room measured at 118 degrees F. Resident bedrooms were toured and observed to have required furnishings and beds had clean linen. LPA observed that R1 has a sliding glass door that leads to the backyard. The sliding glass door was observed to be secured closed with a wooden stick placed on the slider track, preventing the door from being opened. The administrator stated that she did not know it was there and immediately removed the wooden stick to allow the sliding glass door to be opened.

The facility conducts their own laundry and has a washer and dryer. Detergent and chemicals were observed stored in the garage. A second fridge and a freezer were observed in the garage with an additional supply of food. Outside of facility toured and was observed to be free of debris with seatings available for clients under the patio. LPA observed the gate on the left side of the entrance to the house is secured closed with a lock in place, preventing the gate from being opened.

Continued in LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2026
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.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 02/24/2026 03:02 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 02/24/2026 at 02:28 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: GOLDEN VILLA HOME
FACILITY NUMBER: 157201730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 in that LPA observed R1's sliding glass door be secured closed with a wooden stick placed on the slider track, preventing the door from being opened. In addition, the gate on the left side of the entrance to the house is secured closed with a lock in place.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2026
Plan of Correction
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Administrator immediately removed the wooden stick that was securing R1's sliding glass door from opening.
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.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/24/2026 03:02 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 02/24/2026 at 02:28 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: GOLDEN VILLA HOME
FACILITY NUMBER: 157201730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, intereview, and record review, the licensee did not comply with the section cited above in that LPA observed that four out of four residents most recent IPPs on file are over one year old,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2026
Plan of Correction
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Administrator stated that a request will be made to KRC to obtain all four residents IPPs and provide proof to CCLD of request made by POC due date of 03/03/2026. In addition, once IPPs are received Administrator will provide a copy of IPPS to CCLD.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2026


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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: GOLDEN VILLA HOME
FACILITY NUMBER: 157201730
VISIT DATE: 02/24/2026
NARRATIVE
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Continued from LIC 809.

Resident’s medications were reviewed along with the MARs and reflect medication to be administered as prescribed. A fire extinguisher was observed with a receipt purchase date of: 04/09/25. The last fire drill was completed on 01/15/2026, per staff records. Smoke and carbon monoxide detectors were tested and observed to be operational. Staff files were observed to be complete with criminal record statement and health screening. Resident files were reviewed and LPA observed that four out of four residents most recent IPPs on file are over one year old.

Deficiencies are being issued in accordance with the California Code of Regulations, Title 22, see LIC 809D reports. A Fire Clearance Civil Penalty was assessed in the amount of $500.



An exit interview was conducted and a plan of corrections was developed with the administrator. A copy of this report and appeal rights were provided to the administrator.

Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 03/03/2026
NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
LIC809 (FAS) - (06/04)
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