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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003562
Report Date: 04/07/2022
Date Signed: 04/11/2022 07:48:39 AM

Document Has Been Signed on 04/11/2022 07:48 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 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: 3DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Grace Bernardino, AdministratorTIME COMPLETED:
12:40 PM
NARRATIVE
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On 04/07/22 at 9:00 am, Licensing Program Analysts (LPAs) T. White and R. Campbell arrived unannounced to conduct a required 1-year annual inspection. LPAs met with Administrator and explained the purpose of today’s inspection. LPAs was allowed entry into the facility that is licensed to serve a total capacity of 6 residents.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 125.8 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on November 12, 2021. Emergency Disaster Plan last updated 01/02/2022. First aid kit was observed to be complete. Fire drill was last conducted on 03/26/2022. LPAs observed completed mitigation plan.
- LPAs observed hot water temperature in the shared residents bathroom measured at 125.8 degrees F.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/15/2022:
LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.
Exit interview conducted with Administrator. A copy of report and appeal rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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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Document Has Been Signed on 04/11/2022 07:48 AM - It Cannot Be Edited


Created By: Treana White On 04/07/2022 at 12:13 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: 04/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above in 87303(e)(2). LPAs observed hot water temperature measured at 125.8 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
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Administrator agreed to adjust hot temperature and submit proof to CCLD by POC 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:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022


LIC809 (FAS) - (06/04)
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