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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701749
Report Date: 01/15/2026
Date Signed: 01/15/2026 11:56:09 AM

Document Has Been Signed on 01/15/2026 11:56 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 IVFACILITY NUMBER:
342701749
ADMINISTRATOR/
DIRECTOR:		TOLON, WILLIAM J.FACILITY TYPE:
740
ADDRESS:9771 ROEDELL WAYTELEPHONE:
(916) 897-8023
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
01/15/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:William Tolon and Ma. Magnolia TolonTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 1/15/2025, Licensing Program Analyst, Arvin Villanueva (LPA), arrived announced to conduct the pre-licensing inspection visit. LPA met with Licensee, Ma. Magnolia Tolon (S1) and Administrator, William Tolon (S2) and stated the purpose of the visit.

Overview: Facility is a one-story home located in a residential neighborhood. Facility will be licensed to serve up to 6 elderly residents, up to 6 may be non-ambulatory. Facility does have fire clearance for one bedridden, in room #2. No clearance for delayed egress and locked exteriors.

Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas.

Outdoor Area: Front yard was observed to be maintained and clear of debris and obstruction. The backyard equipped with outdoor furniture with umbrella. Outdoor passageways, walkways, driveways, and ramps are free from obstructions. Fence and gate are in good repair. No swimming pools/bodies of water at this time. There is a courtyard for resident use.


Residents' Bedrooms: LPA inspected 6 of 6 resident bedrooms and were observed to be equipped with the required furniture and sufficient lighting throughout. Each bedroom is equipped with smoke detector. Each bedrooms is single occupancy. Room #2 is for bedridden. Each bedrooms have their own exits to the outside. Bedroom #3 of the facility sketch, the exit do not have a ramp. LPA observed the height difference from the door to the pavement is about 2 inches.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2026
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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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 HOME FOR SENIORS LLC IV
FACILITY NUMBER: 342701749
VISIT DATE: 01/15/2026
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Bathroom: Facility has 3 resident bathrooms. Two of the bathrooms are in the hallway and the other bathroom is inside bedroom #5. Bathrooms have working toilets, wash basins and full baths with showers. Bathrooms are equipped with non-skid flooring and close-lid garbage bins.
Linens & Hygiene Supplies: Adequate supply of linen and hygiene supplies stored in linen closet, located in the resident hallway.
Emergency, Exit Plan & Menu: Emergency Disaster Plan will be posted & available for review. One fully charged fire extinguisher was observed at the entrance/foyer. The exit from the dining area going to the backyard did not have a ramp. LPA observed the height difference from the door to the pavement is about 2 inches.
Dangerous Items: Sharp objects, toxins, and chemicals were locked/stored under kitchen sink and in the garage area.
Water and room temperature: Hot water temperature was taken in one bathroom and measured at 112 degrees Fahrenheit. Room temperature was maintained at 73 to 74 degrees Fahrenheit throughout the visit.
Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are in locked cabinet.

Smoke Detectors and carbon monoxide: Smoke detectors were observed in each bedrooms and hallways. One carbon monoxide monitor were observed by the livingroom, at the hallway leading to the kitchen area. S1 tested one smoke detector and one carbon monoxide; both devices were working.

Appliances: Stove burners and oven are in good working condition. Refrigerator/freezer temperature were within regulatory standard. Washer and dryer are located in the laundry room, leading to the garage area.

Medications, First-Aid Kit & Records: First aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in locked cabinet in the kitchen/dining area, available for staff use but inaccessible to residents. There is a medication cabinet that was observed to be locked in the kitchen area.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
Page: 4 of 4
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 HOME FOR SENIORS LLC IV
FACILITY NUMBER: 342701749
VISIT DATE: 01/15/2026
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Residents & Staff Files: Applicant will not be handling cash resources of residents at this time but will submit necessary documents for any changes.

Activity Supplies/Materials: LPA observed activity supplies stored in the kitchen/dining area. Advisory was provided for licensee to provide residents with a variety of activities and choices.

Component III: S1 and S2 waived the Component III review since they completed one back in January 2025.

At this time, the ramps were still in question. LPA contacted CAB analyst to request verification from the fire marshal regarding the ramps if they are needed or not. Once LPA have confirmation regarding the ramps, LPA will return at another date to continue the prelicensing inspection.

An exit interview was conducted and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
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