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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701152
Report Date: 11/18/2024
Date Signed: 11/19/2024 02:13:19 PM

Document Has Been Signed on 11/19/2024 02:13 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 IIFACILITY NUMBER:
342701152
ADMINISTRATOR/
DIRECTOR:
LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:2710 EASTERN AVETELEPHONE:
(916) 613-0647
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 5DATE:
11/18/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:TKTKTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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This report is being amended due to LPA error. Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to amend this report on 11/19/2024. LPAs Moleski and Williams met with Misivono Qadroka and explained the purpose of the visit.

LPA Williams previously cited this facility per 22 CCR Section 87465(h)(2) on 11/6/24. LPA Williams had set the due date for the plan of correction for 11/8/24. LPA Williams received a request for an extension of this due date on 11/08/24. LPA Williams approved this extension on 11/08/24.

On 11/18/24, LPA Williams arrived to conduct a plan of correction visit. LPA Williams erroneously assessed $1,000 worth of daily civil penalties for a failure to correct, despite having previously granted an extension to licensee Diana Garcia, as described above. All civil penalties assessed on 11/18/24 are hereby waived, as they were assessed in error.

LPA Williams received a plan of corrections from Garcia on 11/18/24. LPA Williams cleared the plan of correction during this visit on 11/19/24, and provided Misivono Qadroka with a clearance letter.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Misivono Qadroka .
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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