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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412249
Report Date: 09/08/2022
Date Signed: 09/08/2022 12:17:02 PM

Document Has Been Signed on 09/08/2022 12:17 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GOLDEN OAK RESIDENTIAL CAREFACILITY NUMBER:
336412249
ADMINISTRATOR:ABIGAIL MEJARESFACILITY TYPE:
740
ADDRESS:36190 CHITTAM WOOD PLACETELEPHONE:
(951) 461-9971
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY: 6CENSUS: 5DATE:
09/08/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:LEAD CAREGIVER, CRISTINA UYTIME COMPLETED:
12:18 PM
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Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a case management health and safety visit in conjunction with complaint number 18-AS-20220907152658. LPA Mixson met with Lead Caregiver, Cristina Uy and explained the purpose of the visit.

LPA Mixson toured the facility and observed five residents in the facility and two caregivers. There are no imminent health and/or safety concerns observed at the time of visit. LPA Mixson observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well.

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit.

An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to Lead Caregiver.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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