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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003563
Report Date: 05/25/2021
Date Signed: 05/25/2021 11:03:24 AM

Document Has Been Signed on 05/25/2021 11:03 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 IIFACILITY NUMBER:
347003563
ADMINISTRATOR:BERNARDINO, GRACE C.FACILITY TYPE:
740
ADDRESS:8786 SILVERBERRY AVENUETELEPHONE:
(916) 681-3726
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
05/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Grace BernardinoTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required – 1 Year inspection on 5/25/21 at 8:45am. 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 and upon arrival LPA screened S1. LPA was allowed entry into the facility, screened for COVID precautions, and was accompanied by S1 and Administrator upon arrival and throughout the inspection tour the facility that is licensed to serve a total capacity of 6 non ambulatory and Hospice waiver for 2. Today's census is 5 of which 1 is on Hospice. LPA observed four of four 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 76*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 118.4* and 116.4*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 clients. LPA observed two of two Medication Administration Records (MAR)'s to not be filled out to document of medications administered. S1 stated she administers medications to residents but does not sign off. The first aid kit was observed not found 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.
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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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 II
FACILITY NUMBER: 347003563
VISIT DATE: 05/25/2021
NARRATIVE
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LPA observed food supplies of properly labeled and unexpired 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. LPA observed kitchen knives in a cabinet to the left of the kitchen sink with a towel blocking the lock and personal care items stating "keep out of reach of children" stored in the kitchen and restroom accessible to residents in care. The kitchen was observed clean and in good repair and refrigeration and freezer was within regulatory temperature range. LPA observed stored items not in good repair in the backyard and accessible to residents in care. Administrator stated they will contact for pick up of stored items not in use.

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
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)
Page: 5 of 8
Document Has Been Signed on 05/25/2021 11:03 AM - It Cannot Be Edited


Created By: Ashley Boothe On 05/25/2021 at 10:29 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 YEARS CARE HOME II
FACILITY NUMBER: 347003563

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 two of two Medication Administration Records (MAR)'s to not be filled out to document of medications administered and S1 stated they administer medications 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.
Type A
Section Cited
CCR
87465(a)(9)
Incidental Medical and Dental Care Services
(9) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed the first aid kit was not 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 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 purchase of first aid kit LPA by POC due date.
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)
Page: 7 of 8
Document Has Been Signed on 05/25/2021 11:03 AM - It Cannot Be Edited


Created By: Ashley Boothe On 05/25/2021 at 10:29 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 YEARS CARE HOME II
FACILITY NUMBER: 347003563

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA observed stored items not in good repair in the backyard and accessible to residnets in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2021
Plan of Correction
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The Licensee agrees to submit pictures of items not in good repair removed from the property 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)
Page: 8 of 8
Document Has Been Signed on 05/25/2021 11:03 AM - It Cannot Be Edited


Created By: Ashley Boothe On 05/25/2021 at 10:36 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 YEARS CARE HOME II
FACILITY NUMBER: 347003563

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)

Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA observed kitchen knives in a cabinet to the left of the kitchen sink with a towel blocking the lock and personal care items stored in the kitchen and restroom accessible to residents in care 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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 S1 immediatly removed the towel to secure the knives. The licensee agrees to submit proof of inservice training to maintain compliance with this regulation 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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