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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001886
Report Date: 03/16/2023
Date Signed: 03/16/2023 11:26:06 AM

Document Has Been Signed on 03/16/2023 11:26 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 AC/SC, 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:
03/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Emelita MadriagaTIME COMPLETED:
11:45 AM
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On 03/16/2023 at 8:25 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator Emelita Madriaga and explained the purpose of the visit. Emelita Madriaga assisted with today’s visit. Administrator certificate # is 6004809740 and will expire on 07/17/2023.

The facility has one main Covid-19 screening entry point. The facility has Covid-19 posting throughout the facility. The furniture is spaced six feet apart, and the facility does daily cleaning. The facility has a 30-day supply of PPE. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve six (6) non ambulatory residents. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 104.1 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 07/07/2022. Facility thermostat observed at 70 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to clients. First aid kit was checked and is complete. LPA Lee requested client and staff files for review. LPA Lee reviewed (3) resident files and (2) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA Lee verified
training for staff file reviews.
continue

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2023
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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GOLDEN VALLEY HOME CARE FOR ELDERLY
FACILITY NUMBER: 347001886
VISIT DATE: 03/16/2023
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The following documents was submitted to LPA Lee during today's annual inspection visit.
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC809 (FAS) - (06/04)
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