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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701261
Report Date: 04/24/2024
Date Signed: 04/24/2024 11:10:36 AM

Document Has Been Signed on 04/24/2024 11:10 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 HERITAGE SENIOR CAREFACILITY NUMBER:
342701261
ADMINISTRATOR/
DIRECTOR:		BIGELOW, YELENAFACILITY TYPE:
740
ADDRESS:37 MOSSGLEN CIRTELEPHONE:
(916) 631-0694
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 6CENSUS: 6DATE:
04/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Yelena BigelowTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a complaint investigation. However, upon arrival, LPA Moleski observed multiple deficiencies. LPA Moleski met with facility administrator Yelena Bigelow and explained the purpose of the visit.

Shortly after LPA Moleski had parked his car, around 9 a.m., LPA Moleski observed a resident (R1) walking toward the facility from the community. LPA Moleski observed R1 round a corner from elsewhere in the community and walk to the facility, and enter the backyard through a side gate. R1 was unassisted while out in the community. LPA Moleski entered the facility shortly after R1 and was met by a staff member (S1). S1 provided their name and birth date to LPA Moleski. LPA Moleski reviewed Guardian records and observed that S1 was not associated to this facility. S1 said this was their first day at this facility. LPA Moleski reviewed R1's file and observed that R1 is not able to leave the facility unassisted. LPA Moleski asked S1 if S1 was aware that R1 had taken a walk. S1 said they were not aware. LPA Moleski interviewed R1, who said that R1 had taken a walk to search for cigarette butts. LPA Moleski and Bigelow observed that the alarm on the sliding door into the backyard was not turned on.

This facility is hereby cited per 22 CCR Section 87411(a) and 87355(e)(2). This facility was previously cited per 22 CCR Section 87411(a) on 11/9/23 due to a previous AWOL by R1. As this is a repeat citation, a civil penalty in the amount of $1,000 is hereby assessed. An additional civil penalty of $100 is hereby assessed for one day worked by S1 while not associated to this facility. An exit interview was held with Bigelow. Appeal rights and a copy of this report were left with Bigelow.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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 04/24/2024 11:10 AM - It Cannot Be Edited


Created By: Vincent Moleski On 04/24/2024 at 09:36 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 HERITAGE SENIOR CARE
FACILITY NUMBER: 342701261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2024
Section Cited
CCR
87411(a)

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"(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. ...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:
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Licensee agrees to provide R1 with cigarettes to prevent his elopements, and to install an alarm on the backyard side gate. Additionally, licensee agrees to ensure that all other alarms are regularly checked for functionality. Licensee shall provide LPA Moleski a written plan describing how the above will be accomplished by POC due date.
vincent.moleski@dss.ca.gov
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Based on observation and record review, R1 was in the community unattended, despite being unable to do so per doctor's orders, which poses an immediate health and safety risk.
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Type A
04/25/2024
Section Cited
CCR87355(e)(2)

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"(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: ...

(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) ..."
This requirement was not met as evidenced by:
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Licensee agrees to submit transfer requests for all unassociated staff by POC due date.
Licensee shall cc LPA Moleski on all electronic communication with transfer request staff.
sacasctransferrequest@dss.ca.gov
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Based on observation and record review, S1 worked in this facility without criminal record association, which poses an immediate health and safety risk.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
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