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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701175
Report Date: 06/20/2022
Date Signed: 06/20/2022 02:51:45 PM

Document Has Been Signed on 06/20/2022 02:51 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 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: 5DATE:
06/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Diana GarciaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 6/20/22 at 1:30pm and met with Applicant Diana Garcia and stated the purpose of the visit. This visit is to conduct a Pre-Licensing Inspection. LPA was allowed entry into the home that will be licensed for a capacity of 6.

LPA and Diana Garcia toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed there are 5 residents at this time.
LPA observed the kitchen area, dining area, bedrooms, bathroom, storage areas, and laundry rooms. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature measured at 108.9*F which is within the required range of 105-120*F. The temperature inside the facility measured at 74*F which is within the required range of 68-85*F.
LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed centrally stored medications area to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) and exit alarms on every door in the home. Facility has central heating and air.
LPA observed the area where the staff and resident files are locked and readily available for review.

Component III conducted - There are no objections to licensure at this time. -Licensure pending.


Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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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