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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202451
Report Date: 02/04/2022
Date Signed: 02/04/2022 01:22:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:GOLDEN YEARS III RCHE, THEFACILITY NUMBER:
107202451
ADMINISTRATOR:GALVEZ, MARLENEFACILITY TYPE:
740
ADDRESS:7641 N. MANSIONETTE DRTELEPHONE:
(559) 271-2823
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 6DATE:
02/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Administrator, Carlo Santos and Caregiver, Gina SantosTIME COMPLETED:
01:20 PM
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On 02/04/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Annual Inspection-Infection Control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator, Carlo Santos via telephone, who gave verbal permission for LPA to begin the visit with Caregiver, Gina Santos. Administrator arrived a short time later.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was
readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Bedrooms are single occupant.

LPAs checked residents’ locked medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning supplies were checked. LPA did not observe a sufficient supply of PPE. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. LPA observed 3 out of 6 resident files do not have updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 02/18/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Liability Insurance, Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents, Surety Bond*

No deficiencies were observed. Exit interview was conducted. Administrator was informed that as a COVID-19 precautionary measure, this report will be provided via email. Report was signed on-site by facility representative.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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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