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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057001380
Report Date: 02/13/2023
Date Signed: 02/13/2023 12:19:02 PM

Document Has Been Signed on 02/13/2023 12:19 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:WATCH-GOLDSTRIKEFACILITY NUMBER:
057001380
ADMINISTRATOR:CHRISTINA GARIBAYFACILITY TYPE:
735
ADDRESS:342 GOLDSTRIKE ROADTELEPHONE:
(209) 754-3773
CITY:SAN ANDREASSTATE: CAZIP CODE:
95249
CAPACITY: 12CENSUS: 5DATE:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Susan CollieTIME COMPLETED:
12:30 PM
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On 2/13/23 at approximately 10:10am, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year visit. LPA Met with Susan Collie, care staff, and explained the purpose of today's visit. The Administrator was not available for today's visit however Christina Garibay holds current Administrator certificate # 6037281375 good through 10/29/23.

LPA Jensen toured the facility including but not limited to offices, bathrooms, laundry room, kitchen, pantry, resident rooms and grounds. The grounds were observed to be maintained and all paths were free of obstruction. The thermostat in the facility was set at 68 degrees which falls within the required range of 68-85F degrees. The water temperature was measured at 113.2 degrees and falls within the required regulatory range of 105-120F degrees. The facility was observed to be sanitary.

The fire extinguishers were last serviced on March 2022 and are in compliance. The last fire drill was conducted in January of 2023. The carbon monoxide detectors were tested and food to be in good working order. The first aid kit was observed to be complete. The knives, toxins and medications were observed to be locked and inaccessible to residents in care. LPA Jensen reviewed the medications against the Medication Administration Record (MAR) and found the record keeping to be accurate. PRN administration and effectiveness is also adequately documented.

LPA Jensen observed the bathrooms to have grab bars at the toilet and shower. Non-slip mats are available in all showers. Night lights were present in the bathrooms. All resident rooms have an attached bathroom that is shared with one adjoining resident room. All resident bedrooms are currently single occupancy but several have the ability to be shared.

Continued on LIC 809C....
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2023
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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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: WATCH-GOLDSTRIKE
FACILITY NUMBER: 057001380
VISIT DATE: 02/13/2023
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LPA Jensen observed in excess of a 2 day supply of perishable food and a 7 day supply of no- perishable food. The facility was observed to have a variety of fresh fruit and vegetables on hand. Fruit and snacks are easily accessible to residents in care.

The facility maintains P&I funds. LPA Jensen reviewed the records for P&I funds for resident 1 (R1) and determined the accounting to be accurate. LPA Jensen reviewed the files for R1 and determined all records to be complete and current.

The staff present at the facility were determined to be fingerprint cleared and associated to the facility. The staff present at the facility was determined to have a valid and current first aid certification. The staff maintains an adequate supply of PPE, emergency food and water and linens.

LPA Jensen requested the following documents be emailed to maja.jensen@dss.ca.gov by 2/20/23:

Updated LIC 500
Current Surety Bind
Current Liability Insurance

The facility was determined to be in substantial compliance. No deficiencies were cited as a result of this visit.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
LIC809 (FAS) - (06/04)
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