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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209203
Report Date: 03/23/2022
Date Signed: 03/23/2022 01:51:11 PM


Document Has Been Signed on 03/23/2022 01:51 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:GOLDEN LIFE HAVENFACILITY NUMBER:
107209203
ADMINISTRATOR:GARCIA, CHERRY LYNNEFACILITY TYPE:
740
ADDRESS:247 W SIERRA AVENUETELEPHONE:
(559) 579-2795
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:6CENSUS: 5DATE:
03/23/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Cherry Garcia, LicenseeTIME COMPLETED:
11:15 AM
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On 03/23/22, Licensing Program Analyst (LPA) M. Yang conducted an announced Pre-licensing and Component III inspection. LPA introduced self, stated the purpose of the visit, and was granted entry into the facility. LPA met with caregiver Marietta (Mayette) Padua. Licensee Cherry Garcia was called and arrived shortly. LPA toured the facility with Licensee. There are 5 residents present during this inspection. The facility is 5 bedrooms and 3 bathrooms home. Fire clearance was granted for 6 Non-Ambulatory for total of 6 capacity.

Facility temperature is set to 77 degrees F. Common areas were furnished and had adequate seating and lighting available. Kitchen was toured and observed to have dishes, plate, and utensils. LPA observed a 2 day supply of perishable foods and a 7 day supply of non-perishable foods. Knives were observed to be locked and secure in a lock box in kitchen pantry. Medications were kept in kitchen cabinet locked and inaccessible to residents in care. First aid kit was observed and contained all required items. A fire extinguisher was observed and has a service date of 03/23/22.

All Bedrooms were observed to have required furnishings. Hot water temperature ranged between 112.8 to 115.3 degrees F in bathroom 1 and 108.3 degrees F in bathroom in the shared bedroom. LPA observed an extra supply of bed linens and personal hygiene products.

Cleaning supplies and chemicals were observed to be in a locked cabinet in the garage. Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-closing and self-latching. Smoke detectors and carbon monoxide detectors were observed to be operational during this inspection. All resident records were reviewed. LPA observed resident Admission Agreements and Physician Reports. Staff records were reviewed to have a criminal record clearance.

Component III was conducted during today's pre-licensing visit.

I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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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