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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342701152
Report Date:
08/01/2024
Date Signed:
08/01/2024 03:52:30 PM
Document Has Been Signed on
08/01/2024 03:52 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 LEGACY ELDERLY CARE II
FACILITY NUMBER:
342701152
ADMINISTRATOR/
DIRECTOR:
LEWIS, SALOTE
FACILITY TYPE:
740
ADDRESS:
2710 EASTERN AVE
TELEPHONE:
(916) 613-0647
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95821
CAPACITY:
6
CENSUS:
5
DATE:
08/01/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:
Mareta Teku
TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPAs Moleski and Williams met with staff member Mareta Teku and explained the purpose of the visit. LPA Moleski attempted to reach the licensee and the administrator of this facility but could not reach either of them.
LPA Moleski printed out an updated license reflecting an updated fire clearance and collected this facility's previous license.
No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Teku.
SUPERVISORS NAME
:
Stephen Richardson
LICENSING EVALUATOR NAME
:
Vincent Moleski
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/01/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/01/2024
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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