Community Care Licensing

Document Has Been Signed on 11/09/2023 10:15 AM - It Cannot Be Edited

FACILITY NAME:	GOLDEN HERITAGE SENIOR CARE		FACILITY NUMBER:	342701261
ADMINISTRATOR:	BIGELOW, YELENA		FACILITY TYPE:	740
ADDRESS:	37 MOSSGLEN CIR		TELEPHONE:	(916) 631-0694
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95826
CAPACITY: 6		CENSUS: 6	DATE:	11/09/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Yelena Bigelow		TIME COMPLETED:	10:15 AM

SUPERVISORS NAME: Stephen Richardson LICENSING EVALUATOR NAME: Vincent Moleski LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023

Link to Parent Document Below:

FACILITY NAME: GOLDEN HERITAGE SENIOR CARE	FACILITY NUMBER: 342701261
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/10/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel requirements: "Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services." This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to provide a written plan addressing staffing needs at the facility by the POC due date. Licensee agrees to email LPA Moleski this written plan. Failure to correct the deficiency by the POC due date may result in civil penalties. vincent.moleski@dss.ca.gov
	8 9 10 11 12 13 14	Based on record review and interview, R1 left the facility unassisted on 11/9/23, which poses an immediate health and safety risk.	8 9 10 11 12 13 14
Type B 11/10/2023 Section Cited CCR87211(a)(1)(D)	1 2 3 4 5 6 7	Reporting requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to review reporting requirements and provide a written statement of acknowledgement by the POC due date. Licensee agrees to email LPA Moleski this written statement. Failure to correct the deficiency by the POC due date may result in civil penalties. vincent.moleski@dss.ca.gov
	8 9 10 11 12 13 14	Based on record review and interviews, a resident AWOL was not reported, which poses a potential health and safety risk.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Stephen Richardson LICENSING EVALUATOR NAME: Vincent Moleski LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023