<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701152
Report Date: 07/03/2023
Date Signed: 07/03/2023 09:23:19 AM

Document Has Been Signed on 07/03/2023 09:23 AM - 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:LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:2710 EASTERN AVETELEPHONE:
(916) 613-0647
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: DATE:
07/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Latoya DoweTIME COMPLETED:
09:25 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on 07/03/2023 at 8:45 AM to conduct a case management visit. LPA met with Nadine Mills and Diana Garcia and explained the purpose of the visit.

The purpose of the visit is to follow up on resident's 1 (R1) Dental care plan and Dental visits. During case management visit LPA Martinez reviewed R1's facility files. LPA Martinez will continue to follow up with R1's Dental plan, and will return at a later date. Due to this visit, no deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1