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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003563
Report Date: 10/06/2021
Date Signed: 10/06/2021 12:16:48 PM

Document Has Been Signed on 10/06/2021 12:16 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 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:
10/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Grace BernadinoTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 10/06/2021. LPA met with Grace Bernadino and explained the purpose of the visit.

The purpose of the case management visit is to follow up on a learned deficiency during a complaint investigation.

It was learned resident 1 (R1) was receiving home health services beginning on 05/23/2021 and ending on 09/16/2021. During a facility visit, LPA Martinez reviewed R1's facility file. R1's facility file did not contain a written responsibility agreement between the licensee and the home health agency. The written agreement shall reflect the services, the frequency, and duration of the care that will be provided by the home health agency and by facility staff.

As a result, the facility is not adhering to Title 22 Regulations, and the deficiency can be found on the 809-D report. An exit interview was conducted with Grace Bernadino, and a copy of this report was given to the facility at the end of this visit.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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 10/06/2021 12:16 PM - It Cannot Be Edited


Created By: Avelina Martinez On 10/06/2021 at 09:48 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: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2021
Section Cited
CCR
87609(b)(4)(A)(C)

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87609 Allowable Health Conditions and the Use of Home Health Agencies:The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s)...The written agreement shall reflect the services, frequency and duration of care.
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Grace Bernadino agrees to conduct home health resident enrollment and records training for herself and staff by POC Date 10/27/2021. Grace Bernadino agrees to email LPA training materials and staff sign in sheet by POC date 10/27/2021.
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The written agreement shall be signed by the licensee or licensee representative, and representative of the home health agency, and placed in the resident’s file. This requirement was not met as evidence by: the facility did not have a copy of the home health agency and licensee written care responsibilities agreement. This posed a potential health and safety risk to residents in care.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021


LIC809 (FAS) - (06/04)
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