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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208828
Report Date: 03/27/2023
Date Signed: 03/27/2023 12:18:44 PM


Document Has Been Signed on 03/27/2023 12:18 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:A GOLDEN HEART FAMILY CAREFACILITY NUMBER:
157208828
ADMINISTRATOR:LIGON, MICHELLEFACILITY TYPE:
740
ADDRESS:13402 GIRO DRIVETELEPHONE:
(661) 368-2333
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 6DATE:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Administrator, Michelle Ligon and Administrator Jocelyn LigonTIME COMPLETED:
12:33 PM
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On 03/27/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrators Michelle Ligon and Jocelyn Ligon. Administrators arrived a short time later.

LPA toured the facility with Administrators. LPA toured the facility kitchen. LPA observed an adequate food supply. Resident bedrooms were checked. There are 4 private rooms and 1 shared room. Bedrooms observed to have all required furnishings. LPA toured the resident bathrooms, LPA observed the faucet in bathroom 2 to be leaking with a paper towel wrapped around it to absorb the leaking water. LPA measured hot water temperature. Hot water measured at 117.8 degrees F.

LPA toured the exterior of the facility. All pathways and exits were clear from obstructions. Smoke detector and carbon monoxide detector observed to operational during this inspection. First Aid kit observed to have all required items.

LPA will return at a later date to review resident medications and records, and staff records.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Michelle Ligon, whose signature on this form confirmed receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
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 03/27/2023 12:18 PM - 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 FAMILY CARE
FACILITY NUMBER: 157208828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when the faucet in bathroom 2 was leaking which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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Licensee agrees to have the faucet serviced to stop the faucet from leaking by the POC due date. LPA will return at a later date to confirm the correction has been made.
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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2