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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003562
Report Date: 05/25/2021
Date Signed: 05/25/2021 02:03:05 PM

Document Has Been Signed on 05/25/2021 02:03 PM - 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 YEARS CARE HOME IFACILITY NUMBER:
347003562
ADMINISTRATOR:BERNARDINO, GRACE C.FACILITY TYPE:
740
ADDRESS:8516 FOXBERRY COURTTELEPHONE:
(916) 681-3726
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
05/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Grace BernardinoTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required – 1 Year inspection on 5/25/21 at 12pm. LPA met with Designee, Staff one (S1) and stated the purpose of today’s visit. LPA contacted Administrator prior to today's visit for COVID screening. LPA was allowed entry into the facility, screened for COVID precautions, and was accompanied by Administrator throughout the inspection tour of the facility that is licensed to serve a total capacity of 6 non ambulatory residents with Hospice waiver for 2. Today's census is 5 of which 0 is on Hospice. LPA observed three of three staff associated and cleared in Licensing Information System. LPA observed Administrator Certificate expires on 9/12/2021.

LPA interacted with a random number of residents during this visit. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed resident rooms with required furniture and lighting, common dining and living areas, laundry room, kitchen, storage areas, and property. The temperature inside the facility was measured at 75*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 105.2*F which is within regulatory range of 105*F and 120*F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed one of two Medication Administration Records (MAR)'s to not be filled out to document of medications administered. The first aid kit was observed in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed fire extinguisher(s) last inspected on 10/6/2020, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed chemicals and knives locked and inaccessible to residents.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2021
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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Document Has Been Signed on 05/25/2021 02:03 PM - It Cannot Be Edited


Created By: Ashley Boothe On 05/25/2021 at 01:04 PM
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 YEARS CARE HOME I
FACILITY NUMBER: 347003562

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(7)
Incidental Medical and Dental Care Services
(7) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above in that LPA observed one of two Medication Administration Records (MAR)'s to not be filled out to document of medications administered which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2021
Plan of Correction
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The Licensee agrees to submit proof of in service training to LPA by POC due date.
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:Liza King
LICENSING EVALUATOR NAME:Ashley Boothe
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2021


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 YEARS CARE HOME I
FACILITY NUMBER: 347003562
VISIT DATE: 05/25/2021
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LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed emergency food supplies. The kitchen was observed clean and in good repair.

LPA observed not operational vehicle parked in the driveway and Admininstrator stated it was not working and they are trying to coordinate pick up but because of COVID they have not been successful.

Upon a file review the following items were discussed to be submitted with any changes annually:
Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Qualifications of Administrator Certificate
Emergency Disaster Plan LIC610E
Health Screening Report-Facility Personnel LIC503
In-service Training Program
Medication Procedures
Transportation Procedures
Exemptions/Waivers and Exceptions
First aid/CPR certificates

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
LIC809 (FAS) - (06/04)
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