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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920129
Report Date: 05/29/2024
Date Signed: 05/29/2024 12:28:12 PM

Document Has Been Signed on 05/29/2024 12:28 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 HEART CARE HOME LLCFACILITY NUMBER:
315920129
ADMINISTRATOR/
DIRECTOR:
BOWEN, ROWENA MARY BAUTISTFACILITY TYPE:
740
ADDRESS:780 RED BUD LNTELEPHONE:
(530) 717-5178
CITY:MEADOW VISTASTATE: CAZIP CODE:
95722
CAPACITY: 3CENSUS: 0DATE:
05/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Rowena BowenTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 5/29/2024 LPA Tryon visited the facility to do a pre-licensing visit. LPA met with applicants Rowena and Daniel (Keith) Bowen.
LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, hallways, storage areas, patios, yard. The facility has 4 bedrooms. The licensees will live in one bedroom, and residents in the other 3 rooms. Each room will be a private room, for a total of 3 residents. Room #1 is approved as non-ambulatory as it has an outside exit. The other 2 bedrooms are licensed for ambulatory only residents. The home is clean, nicely furnished. There are large decks on the front and back of the house, with shade, space to sit, eat, etc.
The home has combination smoke/carbon monoxide detectors in hallway and each bedroom. Fire extinguisher present and charged.
Bathroom fixtures are in good condition, clean and operable.
The kitchen is furnished with appropriate dishes, utensils, appliances, etc. Food supplies are present to meet the requirement of 2 days perishable and 7 days non-perishable.
The facility has an appropriately stocked first aid kit and manual, locked storage for chemicals and hazardous materials and objects, locked storage for medications, etc.
The home appears to be safe with no obstacles. The one thing noted is that there are stairs leading from the back deck down to the ground. The stairway is open and a resident could potentially fall off the area onto the ground. The applicants have agreed to cover the area with a gate or other way to ensure safety. LPA asked that the issue be resolved. The applicants agreed to submit proof of correction ASAP, but no later than 10 days, by June 10, 2024.
Otherwise, the home appears to be in substantial compliance with regulations.

LPA reviewed the RCFE Orientation Component III presentation with applicants. Therefore, they have now completed Orientation Component III.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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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