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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201730
Report Date: 02/21/2024
Date Signed: 02/21/2024 02:11:28 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/21/2024 02:11 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 VILLA HOMEFACILITY NUMBER:
157201730
ADMINISTRATOR:SILVA, WENDYFACILITY TYPE:
740
ADDRESS:4420 FOXBORO AVETELEPHONE:
(661) 564-8574
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:4CENSUS: 4DATE:
02/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Administrator, Wendy SilvaTIME COMPLETED:
02:04 PM
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced Annual Inspection visit. LPA Williams met with Administrator Wendy Silva and discussed the purpose of the visit. One resident was sleeping and the rest were out of the facility.

Tour began in the front yard of the facility. The walk ways were free of obstructions.

The kitchen was clean and in good repair. Refrigerator and freezer were stocked with food. Various fruits were observed on the counter and non-perishable items were stored in various kitchen cabinets.

The living room and dining room had seating and space to accommodate all clients. The facility thermostat reflected approximately 72 degrees Fahrenheit (F).

LPA observed four bedrooms with a mattress (with required linens), chair, dresser, night stand, working light, and space to accommodate clients.

Two bathroom were clean and in good repair. Water temperature in the sink reflected approximately 105.5 degrees F. There were grab bars and non slip mats/striper available for resident use.

*Continued on LIC 809C*
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: GOLDEN VILLA HOME
FACILITY NUMBER: 157201730
VISIT DATE: 02/21/2024
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Smoke detector, carbon monoxide, fire extinguisher were present and operational. First aid kit was present and had all required items. Medication were observed locked and inaccessible to clients.

LPA reviewed 4 resident files. All resident and employee files had requested documents.

LPA reviewed 3 employee files, which had all documents requested by LPA.

No deficiency was cited during the visit.

An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC809 (FAS) - (06/04)
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