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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701152
Report Date: 04/29/2022
Date Signed: 04/29/2022 02:14:39 PM

Document Has Been Signed on 04/29/2022 02:14 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GOLDEN LEGACY ELDERLY CARE IIFACILITY NUMBER:
342701152
ADMINISTRATOR:GARCIA, DIANAFACILITY TYPE:
740
ADDRESS:2710 EASTERN AVETELEPHONE:
(916) 613-0647
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 0DATE:
04/29/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Diana Garcia TIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Avelina Martinez arrived announced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA Avelina Martinez met with Diana Garcia who assisted LPA Martinez in today’s pre-licensing inspection.

Facility has a fire clearance for 6 non-ambulatory residents. Diana Garcia, will be the Administrator of this facility. The facility administrator’s holds a current administrator certificate and expires on 01/23/2023.

LPA Martinez inspected the interior and the exterior of the facility including: the common living spaces, resident bedrooms, bathrooms, and kitchen.

The physical plant was sanitary and in good repair. The resident rooms were furnished and sanitary. The resident bathrooms had grab bars and in good repair. The kitchen contained an adequate food supply. The kitchen had plates, cups, an utensils. The facility has a laundry room and all hazards are locked. The facility has resident and staff files set up. The facility has a medication cabinet setup. The facility also has a first aid kit. The facility has all the required posting posted, such as, Administrator certificate, Ombudsman information, personal rights, complaint posting, and LIC 610E ETC. The facility smoke and carbon detectors were tested and in good repair. The facility fire extinguisher was in good repair. The exterior of the facility had a partial covered patio, which contains a patio table and chairs. The exterior emergency gate was in good repair. The facility has submitted a LIC 808 Covid-19 Mitigation plan. In addition, the facility has covid-19 posting throughout the facility. The facility has one central screening entry point. The facility has PPE. The facility will conduct cleaning daily. The facility has a designated area for visits.

The applicant has passed the pre-licensing component of the application process. LPA Martinez will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. Component 3 was waived due to the fact that Diana Garcia has completed Component 3 for another facility, and is an active administrator for another facility. An exit Interview was conducted, and a copy of this report was given to Diana Garcia.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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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