107203439-9-17-2024-24-AS-MVEA-D983G2-20240917181337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107203439
Report Date: 09/17/2024
Date Signed: 09/17/2024 06:13:43 PM

Document Has Been Signed on 09/17/2024 06:13 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	GOLDEN YEARS II, THE		FACILITY NUMBER:	107203439
ADMINISTRATOR:	GALVEZ,MARLENE		FACILITY TYPE:	740
ADDRESS:	9658 N. WINERY AVENUE		TELEPHONE:	(559) 299-8471
CITY:	FRESNO	STATE: CA	ZIP CODE:	93720
CAPACITY:	6	CENSUS: 6	DATE:	09/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Carlo Santos - Administrator		TIME COMPLETED:	06:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/17/2024, Licensing Program Analyst (LPA) M. Vega arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and requested to meet with the Assistant Administrator. Facility staff informed LPA that Administrator was not present in the facility and was granted entry to the facility. Facility staff contacted Administrator (AA), Carlo Santos, who arrived a short time later. Facility tour conducted with AA. All pathways, entrances and exits were clear from obstructions no clearance issue. LPA observed signs promoting hand washing, social distancing, and cough/sneeze etiquette throughout facility. Facility staff observed to be wearing facial coverings. LPA toured the facility kitchen. LPA observed an adequate supply of food. LPA observed a 30-day supply of PPE and cleaning supplies. Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed. Fire extinguisher was observed with a service date of 09/30/2023, All residents’ bedrooms were observed to be with comfortable temperature. Residents’ bathroom was observed, hand washing signs posted, trash can have lid. Medications observed to be locked in a cabinet in the Dining room. LPA reviewed MAR; it appears to be administered properly. Per review of medications, medications were prepared 2 days in advance. Cleaning supplies were observed to be in a locked cabinet in the laundry room. An outdoor seating area was observed for residents in care. LPA reviewed Staff and Resident files. Resident files observed to have update information.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin Vega	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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 09/17/2024 06:13 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GOLDEN YEARS II, THE	FACILITY NUMBER: 107203439
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above in which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/24/2024
	Plan of Correction
1 2 3 4	The licensee stated that will retrain staff on centrally stored medication.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Brenda Chan	TELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin Vega	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GOLDEN YEARS II, THE	FACILITY NUMBER: 107203439
	VISIT DATE: 09/17/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA is requesting the following documents be submitted to the Fresno CCL office by 10/01/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC 308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC 500), Register of Facility Clients/Residents for (LIC 9020A)

Based on observation, a deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D

Exit interview conducted and a plan of correction was reviewed and developed with Assistant Administrator. A copy of this report and appeal rights were discussed and provided to Assistant Administrator, Carlo Santos, the report was signed and copy of this report was provided to Assistant Administrator for facility records.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin Vega	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3