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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057001380
Report Date: 02/12/2025
Date Signed: 02/14/2025 09:46:42 AM

Document Has Been Signed on 02/14/2025 09:46 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WATCH-GOLDSTRIKEFACILITY NUMBER:
057001380
ADMINISTRATOR/
DIRECTOR:		CHRISTINA GARIBAYFACILITY TYPE:
735
ADDRESS:342 GOLDSTRIKE ROADTELEPHONE:
(209) 754-3773
CITY:SAN ANDREASSTATE: CAZIP CODE:
95249
CAPACITY: 12CENSUS: 8DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Kelsey GharabawyTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 02/12/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the live-in caregiver, Kelsey Gharabawy, who was briefly interviewed at this time.
This LPA requested that she go ahead and contact the facility designated Administrator, Christina Garibay, to inform her that CCL was present at this time. It was learned that the facility designated Administrator would not be able to present at today's annual visit with this LPA.
Current census was (8) residents, of which, (5) residents were out of the facility at this time attending their respective day programs.
It was learned that this facility was vendorized through Valley Mountain Regional Center (VMRC) to be able to accept and retain Level 3 residents at any given time.
Tour of the facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed to make sure that this facility had a sufficient supply of plates, dinnerware, and flatware in order to be able to meet the needs of the residents at this time.
Food storage units were observed to be present and in functional order at this time.
A review of the 2-day perishable and 7-day non-perishable food quantities was conducted and observed to be in compliance at this time.
Additional food storage units were observed to be present in other areas of this facility and found to be in compliance at this time.
Medication room, located in the facility office area, was toured. Medications were observed to be stored and made inaccessible to the residents at this time. A review of the facility Medication Administration Record was conducted at this time.
First aid kit was observed to be present and did contain all of the required components at this time.
Laundry area was toured. Cabinets housing detergents, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been recently checked by the local fire extinguisher company, Cisco Fire Sprinklers, on 05/22/2024 and in compliance at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: WATCH-GOLDSTRIKE
FACILITY NUMBER: 057001380
VISIT DATE: 02/12/2025
NARRATIVE
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A tour of the dining area, living area, and all other areas designated for resident use were observed to be furnished and maintained in compliance at this time.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time in compliance.
A tour of the resident restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the resident at this time in compliance.
Hot water temperatures were taken to make sure that the hot water being dispensed for resident use were within the allowed range of 105-120 degrees at all times.
Administrator Certificate for the facility designated Administrator, Christina Garibay, was observed to have the following certificate number 6037281735 set to expire on 10/29/2025 and in compliance at this time.
A tour of the facility exterior grounds was conducted. This facility did not have a surrounding perimeter fence or side gates installed at this time.
A review of the walkways surrounding this facility was conducted.
A review of (3) facility staff files was conducted and noted on the following LIC 859.
A review of (3) facility resident files was conducted and noted on the following LIC 858.

The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308
LIC 400
LIC 500
LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was left with the facility designated representative at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2025 09:46 AM - It Cannot Be Edited


Created By: Charlie Yang On 02/12/2025 at 12:22 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WATCH-GOLDSTRIKE
FACILITY NUMBER: 057001380

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that several window screens had holes, rips, or tears in them which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2025
Plan of Correction
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The facility designated representative stated that a review of all window screens, and sliding glass door screens, will be conducted and any screens with holes, rips, or tears in them will be repaired/replaced as necessary. A statement of correction, along with copies of all receipts for repaired/replacement work completed, will be submitted into CCL by the due date.
Type B
Section Cited
CCR
80070(b)
Client Records
(b) Each record must contain information including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [3] facility resident files did not contain the required forms and documents at this time which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2025
Plan of Correction
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The facility designated representative stated that a review of all facility resident files will be conducted and any records missing required forms and documents will be updated to be in compliance at all times. A statement of correction, along with copies of all updated resident forms and documents, will be completed and submitted into CCL by the due date.
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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
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