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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001886
Report Date: 03/03/2022
Date Signed: 03/03/2022 11:21:45 AM

Document Has Been Signed on 03/03/2022 11:21 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:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:staff Clemente MadriagaTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Anthony Tuck arrived to conduct an unannounced annual/random inspection on 03/03/2020. LPA met with staff Clemente Madriaga and Licensee Emilita Madriaga and explained the purpose of the visit. Emilita Madriaga is also the Administrator and holds certificate #6004809740 that expires on 07/17/2023.

This facility is a single story building licensed to serve six (6) ambulatory residents of which 2 may be non ambulatory at any given time. 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 106.9 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke detectors are in compliance with fire safety. Fire extinguisher last serviced of 07/14/2021. Thermostat was 68 degrees Fahrenheit.
LPA observed centrally stored medications and toxins was kept locked and inaccessible to clients. LPA reviewed staff associations and fingerprint clearance to the facility. First aid kit was checked and is complete.
The following forms need updating and were collected during today's visit on 03/30/2022:
LIC 9020, Copy of current administrator certificate, copy of certificate of liability insurance, LIC 500

No deficiencies were cited during today's visit. Exit interview held with Emelita Madriaga and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2022
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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