342701152-5-22-2023-27-AS-AMAZ-CS3VWH-20230522164754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701152
Report Date: 05/15/2023
Date Signed: 05/22/2023 04:48:40 PM

Document Has Been Signed on 05/22/2023 04:48 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 II		FACILITY NUMBER:	342701152
ADMINISTRATOR:	GARCIA, DIANA		FACILITY TYPE:	740
ADDRESS:	2710 EASTERN AVE		TELEPHONE:	(916) 613-0647
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY: 6		CENSUS: 5	DATE:	05/15/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Charlotte Lewis and Diana Garcia		TIME COMPLETED:	03:00 PM

NARRATIVE

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A virtual Informal conference was conducted today on 05/16/2023 at 1:30 PM via Microsoft Teams. The purpose of the meeting is to discuss complaint allegations and non-compliance concerns. Present in the meeting are Licensing Program Manager Czarrina Camilon-Lee, and Licensing Program Analyst Avelina Martinez, Ombudsman Randi Denning, Licensee Diana Garcia, and facility staff Charlotte Lewis. The informal conference process was explained during this meeting to include the Administrative process.

Discussed Concerns:
The following concerns were discussed: Facility deficiencies, medication errors, administrator changes, reassessments, fire clearance violations, elopements, and Technical Support Program (TSP).

The facility has stated they will do the following to achieve continued and substantial compliance:

Ensure facility has a full time assigned certified Administrator
Ensure all staff are compliant with all required training (medication and reassessments)
Ensure compliance with fire clearance
Facility Administrator will ensure compliance plan is being followed
Ensure all reassessments are being completed
Submit LIC 500 Personnel document and LIC 308 Designated Responsibility document to Community Care Licensing Department (CCLD) by May 22, 2023

Licensee Diana Garcia reported all facility plans to achieve compliance will be submitted to the Community Care Licensing Department by May 31, 2023 5 PM.

Continued...

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 II	FACILITY NUMBER: 342701152
	VISIT DATE: 05/15/2023

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Community Care Licensing Department (CCLD) will do the following:

Increase Monitoring
Technical Support Program (TSP) referral

The licensee was advised failure to follow agreed plan could result in a Non-Compliance Conference.

No deficiencies were cited during today's meeting. An exit interview was conducted with facility representatives Diana Garcia, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

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