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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701152
Report Date: 05/19/2023
Date Signed: 05/19/2023 04:08:40 PM

Document Has Been Signed on 05/19/2023 04:08 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: 6DATE:
05/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:54 PM
MET WITH:Nadine Mills and Charlotte Lewis TIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee arrived at this facility unannounced on 05/19/2023 at 4:00 PM to conduct a case management visit. LPAs met with Nadine Mills and Charlotte Lewis and explained the purpose of the visit.

The purpose of the visit is to follow up on resident's 1 (R1) care plan and relocation plan. LPA Martinez obtained R1's needs and services, admission agreement, Health and Certification form, and Appraisals. LPA Martinez will review the above documents and continue to follow up the relocation of R1.

An exit interview was conducted, and a copy of this 809 report, 809D page, and appeal rights form were provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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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