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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002894
Report Date: 12/10/2024
Date Signed: 12/10/2024 02:52:09 PM

Document Has Been Signed on 12/10/2024 02:52 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: DATE:
12/10/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 12/10/24, LPA Mknelly conducted a POC visit for citations issued on 12/3/24 with POC due by 12/6/24. LPA met with house manager and explained the reason for the visit. LPA spoke with the administrator by phone.

LPA conducted an inspection and spoke with caregivers. LPA found that: A staffing and alert system is in place for resident (R1)who has exit seeking; Door/ exits are unobstructed; all staff are associated and transfer request submitted; and, R2 has been referred for Hospice services.

Related citations have been cleared. Licensee has additional citations that are to be cleared by submitting documents by 12/24/24.


As a result of today's visit, no additional citations are being issued at this time.

Report reviewed and copy provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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