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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701528
Report Date: 01/09/2025
Date Signed: 01/09/2025 11:18:37 AM

Document Has Been Signed on 01/09/2025 11:18 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 HOME FOR SENIORS LLC IIFACILITY NUMBER:
342701528
ADMINISTRATOR/
DIRECTOR:		TOLON, MA. MAGNOLIA M.FACILITY TYPE:
740
ADDRESS:8720 THETFORD COURTTELEPHONE:
(916) 793-9941
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 0DATE:
01/09/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Ma. Magnolia TolonTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived on 1/9/25 at 9:00am to conduct an announced Pre-licensing Visit. LPA was met by Ma. Magnolia Tolon, Applicant and stated the purpose of today’s visit. LPA was allowed entry into the home that will be licensed for a capacity of 6 residents of which 5 may be non-ambulatory and 1 may be bedridden in room #2 only. Hospice waiver approved for 6. Room 7 is fire cleared for staff. Administrator certificate expires 5/5/25 for Ma. Magnolia Tolon.

LPA and Ma. Magnolia Tolon toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. There are 6 bedrooms and 4 bathrooms. All resident rooms contain the required furniture. LPA observed there are no residents at this time. LPA observed the dining area, bedrooms, bathrooms, storage areas, and laundry room. LPA observed area for knives to be locked. LPA observed required furniture, and lighting throughout the facility. The temperature inside the facility measured at 68*F which is within the required range of 68-85*F. The hot water temperature was measured at 108.1*F which is within the required range of 105-120*F. LPA observed kitchen area that contained equipment for cooking and storage for items such as the nonperishable foods for a minimum of one week and perishable foods for a minimum of two days that will be maintained on the premises at all times. LPA observed a copy of the Emergency and Disaster Plan (LIC610E) and Infection Control Plan (LIC9282).

The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed centrally stored medications area that will be locked and inaccessible to residents.
LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the home. Facility has central heating and air. Area that Staff and Resident files will be made readily available for review.

Component III conducted - Licensure pending. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. Exit interview held, copy of report given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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