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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002894
Report Date: 12/03/2024
Date Signed: 12/03/2024 04:07:39 PM

Document Has Been Signed on 12/03/2024 04:07 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOLDEN HILLS CARE HOMEFACILITY NUMBER:
315002894
ADMINISTRATOR/
DIRECTOR:		MAHAJAN, VIVEKFACILITY TYPE:
740
ADDRESS:1434 ELM STREETTELEPHONE:
(916) 474-4920
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 5DATE:
12/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:caregiverTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 12/3/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with caregiver Louis Dizon(S1).

On 11/27/24, the department received an incident report for R1 having left the home unassisted on 11/22/24. LPA reviewed the LIC 602 for R1 and found that R1 is to not leave unassisted. On 11/22/24, S1 was the lone caregiver present, while S1 was assisting R2, R1 left the facility. S1 discovered R1 missing, called 9-1-1 for assistance. R1 was found by police and returned unharmed. This licensee has received a prior citation related to R1 leaving in June 2023. It is found that there were not adequate staff present to meet the needs of residents.

While LPA was present, a Health and Safety Check was conducted for all residents. LPA conducted a file review for R2. R2 was receiving home health care for pressure injuries. LPA attempted to contact home health regarding the status of R2's pressure injuries. R2 was unwilling to be interviewed by LPA.
LPA may return after receiving further information regarding R2.

During this inspection, LPA observed, accompanied by S1, that facility staff had installed locking mechanisms on several exit doors and has a locking mechanism for the front door on the overnight.
Mechanisms were removed while LPA was present. These locks violate fire safety regulations.

File reviews for R1 and R2 found that there are not current detailed needs and services plans for R1's wandering or for R2's wounds, incontinence or bed repositioning. Licensee was advised during a 5/29/24 Annual inspection to have needs and services plan in place.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN HILLS CARE HOME
FACILITY NUMBER: 315002894
VISIT DATE: 12/03/2024
NARRATIVE
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Caregiver S2 has worked at this facility greater that 5 days without transfer of criminal record clearance. LPA checked clearance and found S2 to have clearance but was not associated to this home.

Given the issues found during this visit, it was found that Administrator, Vivek Mahajan, is not present at the facility to fulfill the duties and responsibilities of the facility/ residents.

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed. Copy of report and appeal rights provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/03/2024 04:07 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 12/03/2024 at 03:14 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN HILLS CARE HOME
FACILITY NUMBER: 315002894

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2024
Section Cited
CCR
87411(a)

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Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met based on report and interviews. This posed an immediate risk to R1.
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Licnensee will submit a plan for supervision and alarms that ensure close supervion of R1 during all hours of the day, by the POC date of 12/4/24.

To be cleared by POC visit.
Type A
12/04/2024
Section Cited
CCR
87203

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Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marsha... This requirement was not met based on observation of ubstructed exits. This posed and immediate risk to residents.
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Locks and obstructions were removed while LPA was present. Licensee will submit proof of training for staff to not use such devices and a schedule for Administrator to conduct at least weekly compliance checks of the home, by the POC date of 12/4/24.
Type B
12/06/2024
Section Cited
CCR87355(c)

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Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another. This requirenment was not met based on record review and interview. This posed a potential risk to residents.
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Licensee will submit a transfer request for S2 to CCLD via fax or Guardian and notify LPA when completed, by the POC date of 12/6/24
Type B
12/06/2024
Section Cited
CCR
87631

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87631 Healing Wounds (a) ...accept or retain... a healing wound ...: (3) Residents with a stage one or two pressure injury ...(A) ...shall receive care...from a...appropriately skilled professional. This requirement was not met based on lack or records for staging or care. This posed a potential risk
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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:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/03/2024 04:07 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 12/03/2024 at 03:34 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN HILLS CARE HOME
FACILITY NUMBER: 315002894

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2024
Section Cited
CCR
87467

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Resident Participation in Decisionmaking (a) Prior to, or within two weeks of the resident’s admission, ... to prepare a written record of the care the resident will receive in the facility...This requirement was not met based on records review. This posed a potential risk for resdents.
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Licensee will create Needs and Services Plans using the LIC 625, or the information on the form, for all residents and submit the forms to LPA by the POC date of 12/24/24.
If not signed by residents or responsible parties, Licensee will stae when meetings are scheduled.
Type B
12/24/2024
Section Cited
CCR
87405(a)

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Administrator - Qualifications and Duties (a) ...The administrator shall ... shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. This requirement was not met based on the issues
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Licensee will submit a LIC 500 identifying when Admin and staff will regularly be present at the faciliy. Additionally, Licensee will submit a written plan for the duties and task to be completed when present to ensure compliance with Title 22 requirements.
Documents to be submitted by 12/24/24.
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and citations noted in this visit. This poses a potential risk to residents.
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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:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
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