<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201730
Report Date: 02/23/2023
Date Signed: 02/27/2023 08:55:47 AM


Document Has Been Signed on 02/27/2023 08:55 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:GOLDEN VILLA HOMEFACILITY NUMBER:
157201730
ADMINISTRATOR:SILVA, WENDYFACILITY TYPE:
740
ADDRESS:4420 FOXBORO CT.TELEPHONE:
(661) 564-8574
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:4CENSUS: 4DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Co Administrator, Joan AquinoTIME COMPLETED:
01:23 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
Licensing Program Analyst (LPA) Darius Wiliams conducted an unannounced Annual Inspection visit. LPA Williams met with Co Administrator, Joan Aquino and discussed the purpose of the visit. No residents were present in the facility.

LPA Williams toured the facility with Co- Administrator.

LPA Williams observed a visitor/temperature log at the front entrance. Facility has one entry and exit point. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA Williams observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies and medications were observed behind a locked door. LPA Williams observed the following personal protective equipment in storage; gowns, face shield, gloves, and masks.

Staff have received training regarding Covid-19 infection control and mitigation. 4 of 4 resident's files had updated emergency contact information.

LPA Williams requested the following updated documents be sent to the Department by 3/1/2023 ; personnel report (LIC 500) ,designation of facility responsibility (LIC 308),and administrator certificate.

No deficiencies were observed or cited at this time.

Exit interview was conducted and a copy of this report will be provided via e-mail.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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 1