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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003563
Report Date: 03/08/2024
Date Signed: 03/08/2024 04:04:28 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2024 and conducted by Evaluator Victoria Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240307160247
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: 6DATE:
03/08/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Grace BernardinoTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff do not ensure that resident's needs are met
Staff do not keep the facility free of cockroaches
Staff are not able to communicate with residents
Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to investigate the above mentioned allegations on 3/8/24 at 1:45p. LPA met with Administrator Grace Bernardino and stated the purpose of the visit.

LPA conducted a tour of the facility, resident rooms, and furniture. LPA obtained a copy of the staffing schedule for March 2024. LPA conducted interviews of residents, staff and Administrator during this visit.

R1 - R3, S1-S2, and Administrator stated there is always staff available when needed during day and night.

LPA did not observe roaches in the facility. LPA observed food items in the bed, table(s) and closet of R1 but did not observe any insects or droppings. LPA observed the product Ortho Home Defense that the Administrator is using to avoid insects in the home.

Unfounded
Estimated Days of Completion: 30
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20240307160247
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN YEARS CARE HOME II
FACILITY NUMBER: 347003563
VISIT DATE: 03/08/2024
NARRATIVE
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R1 - R3, S1-S2, and Administrator stated the staff communicates in English to them all the time.

R1 - R3, S1-S2, and Administrator stated there has not been any medication errors. LPA observed the MARs during this visit.

The investigation revealed that the allegations mentioned above are unfounded at this time.

"The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint."


Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2