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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206942
Report Date: 08/08/2022
Date Signed: 08/08/2022 11:29:44 AM


Document Has Been Signed on 08/08/2022 11:29 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:A GOLDEN HEARTFACILITY NUMBER:
157206942
ADMINISTRATOR:LIGON, JOCELYNFACILITY TYPE:
740
ADDRESS:13209 INDURAN DRIVETELEPHONE:
(661) 368-2213
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 5DATE:
08/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Licensee Michelle Ligon and Administrator Jocelyn LigonTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst LPA Shawna Doucette and Vadim Gorban conducted an Annual Infection Inspection on this date. LPA was met by Staff and discussed the purpose of the visit. Licensee Michelle Ligon responded to the facility to assist with the inspection. LPA and Licensee Michelle Ligon began the tour at the front entrance/office of the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Covid-19 related signs were observed in the common areas.

Cleaning supplies were observed locked in hall closet. LPA observed the following personal protective equipment in a storage cabinet; gowns, gloves, face shields, hand sanitizer and masks. LPA observed all facility staff to be wearing masks upon arrival.

Resident’s files have updated emergency contact information. LPA's reviewed staff training for Covid.

See 809D for deficiency. Civil Penalties were issued for added staff bedroom in garage that is not fire cleared.

Exit interview was conducted and a copy of this report and appeal rights were provided
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
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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Document Has Been Signed on 08/08/2022 11:29 AM - It Cannot Be Edited

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: A GOLDEN HEART
FACILITY NUMBER: 157206942

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
87202 Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by adding a staff bedroom in the garage that is not fire cleared which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2022
Plan of Correction
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Licensee agrees to submit a plan on whether or not the room will be removed or cleared by fire by POC due date 8/31/22. Civil Penalty was issued.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
LIC809 (FAS) - (06/04)
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