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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209203
Report Date: 03/28/2024
Date Signed: 03/28/2024 02:57:14 PM


Document Has Been Signed on 03/28/2024 02:57 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: 4DATE:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator Cherry GarciaTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection.LPA disclosed the purpose of the inspection and was granted entry into the facility by caregiver staff who contacted the Administrator to respond to the facility to assist with the visit. LPA met with Administrator Cherry Garcia.

A tour of the facility was conducted with the Administrator. .

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication cart and in a locked medication room. Cleaning supplies were in a locked storage closet. Facility smoke detectors were checked and operating. Fire extinguishers were charged and had service dates of 3/06/24. Facility has a pull station fire alarm. Last emergency drill was conducted on 3/21/24..

There was outdoor seating for the residents.

Facility has a pool that is gated with lock on gate making it inaccessible to residents in care.

Resident, medication and staff records were reviewed. Current CPR first aid was on file for staff.

An exit interview was conducted with the Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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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