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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201730
Report Date: 10/04/2022
Date Signed: 10/04/2022 10:10:40 AM

Document Has Been Signed on 10/04/2022 10:10 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:
10/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joan Aquino, Co-AdministratorTIME COMPLETED:
10:25 AM
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 10/4/22 at 9:00 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - deficiency inspection. LPA explained reason for inspection and was granted entry. LPA met with Co-Administrator (ADM) Joan Aquino.

During record review for complaint #24-AS-20220927174248, LPA found that R1 did not have a complete medical assessment. The medical assessment on file was missing the primary diagnosis, secondary diagnosis (if any), prior medical services/history, indication of whether medication should be centrally stored, identification of physical limitations, ambulatory status, and was not signed by a physician, or any information applicable to the pre-admission appraisal.

R1 was admitted to the facility on 10/12/21. ADM advised the medical assessment on file was given by Kern Regional Center as a part of the placement into the facility. ADM stated the facility waits one year before obtaining another medical assessment.

A deficiency is being cited based on LPA interview conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted and a Plan of Correction was developed and reviewed with Co-Administrator Joan Aquino. A copy of this report and appeal rights were given to Co-Administrator Joan Aquino, whose signature confirms receipt of this report.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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 2
Document Has Been Signed on 10/04/2022 10:10 AM - It Cannot Be Edited


Created By: Malia Thao On 10/04/2022 at 09:51 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GOLDEN VILLA HOME
FACILITY NUMBER: 157201730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2022
Section Cited
CCR
87458(a)

1
2
3
4
5
6
7
87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit proof of a completed medical assessment for R1 to CCL by POC due date.
8
9
10
11
12
13
14
LPA found that R1 did not have a complete medical assessment. The medical assessment on file was missing the primary diagnosis, secondary diagnosis (if any), prior medical services/history, indication of whether medication should be centrally stored, identification of physical limitations, ambulatory status, and was not signed by a physician, or any information applicable to the pre-admission appraisal, which poses a potential health, safety, or personal rights risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2