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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002509
Report Date: 08/16/2023
Date Signed: 08/16/2023 01:31:29 PM


Document Has Been Signed on 08/16/2023 01:31 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: DATE:
08/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Aaron Murillo TIME COMPLETED:
12:31 PM
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On 08/16/2023, Licensing Program Analyst (LPA) Jaynae Boyles and Licensing Program Manager (LPM) Lauren Crocker, arrived at the facility announced to conduct a Pre licensing Inspection. LPA's met with Facility Administrator, Aaron Murillo and explained the purpose of the visit.
LPA Boyles, LPM Crocker, and Administrator Murillo toured facility together to ensure that the facility is ready to take its first clients in this care home for seniors has a dementia program on file. Areas toured include but are not limited to: common areas, bedrooms, garage, backyard, and restrooms. LPA observed the facility to be clean, in good repair and odor-free with trash can with lids. The facility was equip with required fire extinguishers, fire detectors and carbon monoxide detectors. The facility was stocked with the required two day perishable and 7 day non-perishable amount of food for residents and staff.

Component III will be conducted after corrections are received via a virtual meeting.

The items noted on the attached LIC 809D need to be addressed prior to the facility getting licensed. These corrections are also documented on the application for Emerald Dreamcare Home, License #045003022:

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 917-3040
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 08/16/2023 01:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GOLDEN SIERRA CAREHOME INC
FACILITY NUMBER: 045002509

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2023
Section Cited
CCR
87303(e)(3)

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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' F and not more than 120' F.
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Administrator shall lower the water temperature of the facility to read between 105'F and 120'F.
Send proof of correnction.
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The facility's water measured at 142 during todays inspection.
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Type A
08/17/2023
Section Cited
CCR87203

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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. LPA observed a lock on an interior door to the outside in a residents room that rendered it inoperable.
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Administrator/Licensee shall remove any locks from exits that render doors inoperable and shall maintain in accordance with the fire clearance approved on file.
Send proof of lock removal by 8/17/23
Type B
08/30/2023
Section Cited
CCR
87608(a)(3)

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A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. LPA observed 1/2 rails on 3 beds with no orders on file.
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Administrator/Licensee shall obtain orders for 1/2 rails for all residents with bedrails to be used as postural supports/ambulation. Retain a copy of the orders in the residents files or remove the 1/2 rails.
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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 917-3040
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/16/2023 01:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GOLDEN SIERRA CAREHOME INC
FACILITY NUMBER: 045002509

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2023
Section Cited
CCR
87705

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The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment,
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Obtain current MD reports for all residents with dementia (within 12 months) and ensure all exits are alarmed and on at all times.
Send proof of correction.
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and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
LPA observed exit alarms to be in the "off" position and/or need repair. LPA observed outdated MD report for resident with dementia.
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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 917-3040
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3