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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701175
Report Date: 05/27/2022
Date Signed: 05/27/2022 10:18:28 AM

Document Has Been Signed on 05/27/2022 10:18 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 III ELDERLY CAREFACILITY NUMBER:
342701175
ADMINISTRATOR:GARCIA, DIANAFACILITY TYPE:
740
ADDRESS:7695 RIVER VILLAGE DRTELEPHONE:
(916) 400-4098
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 6DATE:
05/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Benjamin Aboagye-Danso CaregiverTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Pre-licensing inspection on 5/27/22 at 9:30am. LPA met with Benjamin Aboagye-Danso Caregiver and stated the purpose of the visit.

LPA was unable to reach to applicant as all contact information is for the facility.

LPA contacted the previous Administrator for Love and Serenity IV (Mike Her) who attempted to contact the Applicant and provided a phone number.

LPA left a message for a call back. LPA received a text indicating Applicant is out of town and need to reschedule the visit. LPA informed Applicant that the visit shall be unannounced as there are clients present.

Due to the Applicant being unavailable for this visit, the Pre-licensing visit will be conducted on a later date.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
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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