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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001886
Report Date: 05/21/2021
Date Signed: 05/21/2021 11:23:23 AM

Document Has Been Signed on 05/21/2021 11:23 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GOLDEN VALLEY HOME CARE FOR ELDERLYFACILITY NUMBER:
347001886
ADMINISTRATOR:MADRIAGA, EMELITA H.FACILITY TYPE:
740
ADDRESS:7622 COUNTRY PARK DRIVETELEPHONE:
(916) 682-1322
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 5DATE:
05/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee Emilita MadriagaTIME COMPLETED:
11:47 AM
NARRATIVE
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Licensing Program Analyst (LPA) Anthony Tuck Kevin Gould Island arrived to conduct an unannounced annual/random inspection on 05/21/2020. LPA met with Licensee Emilita Madriaga and explained the purpose of the visit. Emilita Madriaga is also the Administrator and holds certificate #6004809740 that expires on 07/17/2021.

This facility is a single story building licensed to serve six (6) ambulatory residents. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 105 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke detectors are (blank) in compliance with fire safety. Fire extinguisher last serviced July 13 of 2020. Thermostat was 68 degrees Fahrenheit.
LPA observed centrally stored medications and toxins was kept locked and inaccessible to clients. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed resident files,. LPA reviewed associations to the facility. First aid kit was checked and is complete.
The following forms need updating and submitted to CCLD by 05/24/2020:
LIC 308
LIC 500
LIC 610E
Copy of current administrator certificate
continued on 9099C
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GOLDEN VALLEY HOME CARE FOR ELDERLY
FACILITY NUMBER: 347001886
VISIT DATE: 05/21/2021
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LPA learned that the facility currently has 2 residents that are non ambulatory. The facility does not have a fire clearance for non ambulatory residents.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, Type A deficiencies are being cited today in violation of California Code of Regulations and follows on 809D. Exit interview held with Emilita Madriaga and a copy of report given at the conclusion of the visit.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/21/2021 11:23 AM - It Cannot Be Edited


Created By: Anthony Tuck On 05/21/2021 at 10:40 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN VALLEY HOME CARE FOR ELDERLY
FACILITY NUMBER: 347001886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(b)
Limitations -Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, LPA's reviewed 5 LIC 602 physicaian assesments for residents, LPA's found 2 of the 5 residents are desiganted as non ambulatory by their physician. The licensed capacity of the home is for 6 ambulatory residents The licensee did not comply with the section cited above in 2 out of 5 persons, which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/24/2021
Plan of Correction
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Licensee will be submitting a new LIC 200 to address their non-ambulatory capacity and obtain a new fire clearance with a non ambulatory capacity of 2.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Anthony Tuck
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2021


LIC809 (FAS) - (06/04)
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