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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701175
Report Date: 06/28/2024
Date Signed: 06/28/2024 11:51:45 AM

Document Has Been Signed on 06/28/2024 11:51 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOLDEN LEGACY ELDERLY CARE IIIFACILITY NUMBER:
342701175
ADMINISTRATOR/
DIRECTOR:		GARCIA, DIANAFACILITY TYPE:
740
ADDRESS:7695 RIVER VILLAGE DRTELEPHONE:
(916) 400-4098
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 6DATE:
06/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Kimberly SloanTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 6/28/24 at 9:30am Licensing Program Analyst (LPA) Kevin Gould arrived at Golden Legacy Elderly Care III (RCFE) for the purpose of conducting a required 1 year annual inspection. LPA met with Staff, Kimberly Sloan and together conducted a tour of the home.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 117 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed medications, not centrally stored or secured from residents. LPA observed several medications and inhalers in common areas not secured from residents. Additionally, LPA observed unused needles stored in a unsecured cabinet along with the needle disposal container.

LPA also observed a resident with dementia who retains their own lighter for smoking cigarettes. The facility is retaining cigarettes for resident but other residents also leave their cigarettes in common areas accessible to residents with dementia.

Report Continued on LIC 9099-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2024
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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Document Has Been Signed on 06/28/2024 11:51 AM - It Cannot Be Edited


Created By: Kevin Gould On 06/28/2024 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN LEGACY ELDERLY CARE III
FACILITY NUMBER: 342701175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above as LPA observed several medications (inhalers) and unused needles not centrally stored or secured from residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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A written plan of correction will be submitted indicting the steps facility will take to ensure all medications and equipment are stored locked and inaccessible to residents in care.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations the licensee did not comply with the section cited above as LPA confirmed resident with dementia is retaining a lighter for smoking cigarettes which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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facility will submit a written plan of correction indicting the steps facility will take to secure items such as lighters and matches used from smoking and how the items will be made available to resident upon request and how they will be secured after use.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/28/2024 11:51 AM - It Cannot Be Edited


Created By: Kevin Gould On 06/28/2024 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN LEGACY ELDERLY CARE III
FACILITY NUMBER: 342701175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above as LPA observed cigarettes to be unsecured and left on an outside table along with a lighter which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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facility will submit a written plan of correction indicting the steps facility will take to secure items such as cigarettes used from smoking and how the items will be made available to resident upon request and how they will be secured after use.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 III
FACILITY NUMBER: 342701175
VISIT DATE: 06/28/2024
NARRATIVE
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LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 9020 client roster and current administrator certificate.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC809 (FAS) - (06/04)
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