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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701261
Report Date: 04/14/2025
Date Signed: 04/14/2025 12:59:29 PM

Document Has Been Signed on 04/14/2025 12:59 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 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:
04/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Lyenna BigelowTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski spoke with facility administrator Lyenna Bigelow over the phone and explained the purpose of the visit.

LPA Moleski reviewed six resident files (R1-R6) and three staff files (S1-S3). R2 was identified as bedridden on their latest LIC 602, dated 02/07/2025. Comments on the LIC 602 describe the resident as "bed bound," and suffering from motor impairment or paralysis. R2's latest appraisal, dated 02/18/2025, indicated that R2 was in bed all the time. In an interview during this visit, S1 referred to R2 as "bed bound." This facility has a fire clearance for six non-ambulatory residents, but is not cleared to accept or retain any bedridden residents.

Medical records from an emergency room visit on 2/24/25 indicate that R3 received a CT scan of their head due to a "fall/ qeustionable [sic.] head injury." The CT scan revealed no internal bleeding or other signs of serious injury. LPA Moleski reviewed fax and email records and observed that no incident reports were received regarding this fall.

LPA Moleski observed that three residents' admission agreements (R3, admitted 1/27/25, R4, admitted 2/10/25, and R6, admitted 3/14/25) did not include base rates for basic services.

LPA Moleski toured the facility and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 69 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. [continued on 809-C]
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Vincent Moleski
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 HERITAGE SENIOR CARE
FACILITY NUMBER: 342701261
VISIT DATE: 04/14/2025
NARRATIVE
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The facility's water temperature was tested and measured 103 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees.

While touring the facility, LPA Moleski observed that the interior garage door was unlocked. LPA Moleski observed many cleaning solutions and chemicals out in the garage. A cabinet labeled "keep locked when not in use" and "must be locked at all times" was unlocked. Several different cleaning solutions were observed inside the unlocked cabinet. LPA Moleski observed one resident (R6) walk into the garage unaccompanied during this visit.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked closet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed one staff member (S1). Residents were not able to be interviewed during this visit.

This facility is cited per 22 CCR Sections 87202(a)(2), 87309(a), 87211(a)(1), 87303(e)(2) and 87507(g)(3)(A). Due to a violation of fire clearance requirements, an immediate civil penalty in the amount of $500 is hereby assessed. An exit interview was held with Bigelow. Appeal rights and a copy of this report were left with staff member Siteri Senitirau.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Vincent Moleski
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/14/2025 12:59 PM - It Cannot Be Edited


Created By: Vincent Moleski On 04/14/2025 at 12:23 PM
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: 04/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(g)(3)(A)
"Admission agreements shall specify the following: ... Payment provisions, including the following: ... Rate for all basic services which the facility is required to provide in order to obtain and maintain a license..." This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on record review, base rates were not specified in three resident admission agreements, which poses a potential health, safety, and/or personal rights risk.
POC Due Date: 04/18/2025
Plan of Correction
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2
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Licensee agrees to send LPA Moleski updated admission agreements by POC due date. vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2025 12:59 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Vincent Moleski On 04/14/2025 at 12:28 PM
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: 04/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, a bedridden resident was retained, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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Licensee agrees to provide a written plan of correction to LPA Moleski by POC due date.
vincent.moleski@dss.ca.gov
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, cleaning solutions and other chemicals were unlocked and accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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Licensee agrees to relocate all offending substances to appropriately locked storage by POC due date. Licensee further agrees to send LPA Moleski a photograph of the locked storage area.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 04/14/2025 12:59 PM - It Cannot Be Edited


Created By: Vincent Moleski On 04/14/2025 at 12:28 PM
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: 04/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, a resident suffered a fall which needed emergency medical examination, but an incident report was not received by CCLD within the appropriate time frame, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with a written plan regarding reporting requirements by POC due date.
vincent.moleski@dss.ca.gov
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, water temperatures were below the required threshold, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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Licensee agrees to raise the water temperature and provide LPA Moleski a photograph of the new reading by POC due date. vincent.moleski@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2025


LIC809 (FAS) - (06/04)
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