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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002509
Report Date: 02/08/2023
Date Signed: 02/08/2023 10:41:44 AM


Document Has Been Signed on 02/08/2023 10:41 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,
, CA



FACILITY NAME:GOLDEN SIERRA CAREHOME INCFACILITY NUMBER:
045002509
ADMINISTRATOR:QUIAMBAO, EDGARDO C.FACILITY TYPE:
740
ADDRESS:2289 BAR TRIANGLE STREETTELEPHONE:
(530) 774-7929
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:6CENSUS: 1DATE:
02/08/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:May Quiambao - LicenseeTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Annual/Random Inspection Visit utilizing the infection control domain. LPA met with licensee and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA Wallace was screened by staff.

LPA Wallace and licensee toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident rooms, common bathrooms, dining room, visiting area and storage areas. LPA observed sufficient seven day non-perishable and two day perishable food supplies. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Wallace and licensee completed the infection control domain and facility was found to be in substantial compliance at this time.

Hot water temperature was measured at 107.5 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers were last inspected on . Smoke and carbon monoxide detectors are in compliance with fire safety. Thermostat observed at (75) degrees Fahrenheit. LPA reviewed one (1) resident record and two (2) staff records. All documents were complete and staff have current first aid certificates.

No deficiencies are being cited as a result of today's inspection.

Exit interview conducted and copy of report was provided to licensee at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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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