<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342701175
Report Date:
07/09/2024
Date Signed:
07/09/2024 03:02:33 PM
Document Has Been Signed on
07/09/2024 03:02 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 III
FACILITY NUMBER:
342701175
ADMINISTRATOR/
DIRECTOR:
GARCIA, DIANA
FACILITY TYPE:
740
ADDRESS:
7695 RIVER VILLAGE DR
TELEPHONE:
(916) 400-4098
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95831
CAPACITY:
6
CENSUS:
6
DATE:
07/09/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:
Gloria Clarke-Daley
TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/9/24 at 3:00pm Licensing Program Analyst (LPA) Kevin Gould Conducted an unannounced Plan of Correction (POC) inspection to ensure previous deficiencies have been corrected and there are no current health and safety issues.
LPA conducted the inspection and observed all medications made inaccessible to residents in care and cigarettes and lighters in the home used by residents are stored secured from residents with a diagnosis of dementia.
POC clearance letters were generated 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:
07/09/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
1