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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700800
Report Date: 08/14/2025
Date Signed: 08/14/2025 01:23:41 PM

Document Has Been Signed on 08/14/2025 01:23 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOLDEN HOME FOR SENIORSFACILITY NUMBER:
342700800
ADMINISTRATOR/
DIRECTOR:		TOLON, MA MAGNOLIA MFACILITY TYPE:
740
ADDRESS:8701 MILO COURTTELEPHONE:
(916) 686-2129
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
08/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH: MAGNOLIA M TOLON,TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 08/14/2025 unannounced annual inspection was made to this facility by Licensing Program Analyst (LPA) Sommer Hayes. The LPA identified themselves and the purpose of the visit and asked to speak to the Designated Facility Administrator (DFA). LPA was met by Administrator, Ma Magnolia Tolon, and a brief interview followed. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 residents. The current census is 6.


LPA Hayes toured the facility with the Designated Facility Administrator (DFA), Ma Magnolia Tolon. The kitchen was accessible to residents and clean and sanitary. The LPA observed 7 days of non-perishable and 2 days of perishable food supplies. There is enough clean plates, cups and bowls and cutlery to meet capacity. Opened packages in the refrigerator were dated appropriately.

Staff were observed assisting residents with activities of daily living (ADLs), cleaning the home and engaging with resident in care. Residents were observed working on a puzzles, eating, watching television, and in their bedrooms.

Water temperature measured 107 degrees F within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire extinguishers inspected were charged on 05/06/25 by River City Fire and was in compliance. A dual smoke detector/carbon monoxide in hallway was tested and working. There was enough lighting in all common areas, resident rooms, and hallways. A first aid kit was observed containing a first aid manual, tweezers, scissors, gauze and Band-Aids.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Sommer Hayes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN HOME FOR SENIORS
FACILITY NUMBER: 342700800
VISIT DATE: 08/14/2025
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LPA Hayes reviewed 6 resident files and 2 staff records during this visit. Medication was centrally stored and secured. The medication administration record (MAR) was reviewed and found to be complete with accurate documentation of administered medications provided to residents.


LPA Hayes observed the backyard of the facility to be clean and free of hazards. There was a shaded area for residents to enjoy. Fencing was in good repair. There were no bodies of water.

The facility living room was clean and free of obstruction. The temperature reading was 74 degrees Fahrenheit per Title 22 regulations. The seating is efficient for the number of residents in this facility.

LPA Hayes requested the following annual documents for the facility file: LIC 500 Personnel Report, LIC 308 Designation of Responsibility, LIC 610 Emergency Disaster Plan, LIC 999 Facility Sketch, Copy of Administrator’s Certificate.

Per California Code of Regulations (CCR) - Title 22, 0 deficiency are being cited. An exit interview was held, and a copy of the report was provided to Designated Facility Administrator, Ma Magnolia Tolon.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Sommer Hayes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
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