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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208828
Report Date: 03/20/2024
Date Signed: 03/20/2024 12:36:00 PM


Document Has Been Signed on 03/20/2024 12:36 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: 5DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Administrator, Michelle Ligon and Administrator Jocelyn LigonTIME COMPLETED:
12:50 PM
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On 03/20/2024, 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 the Administrator via telephone. Administrators arrived a short time later. LPA met with Administrator, Michelle Ligon and Administrator Jocelyn Ligon.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 112.7 degrees F and 115.2 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 04/10/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 01/14/2024. All cleaning supplies are locked and secure in the laundry room.

LPA reviewed staff and client records. Medications reviewed and observed to have original labels and be administered as prescribed. First Aid Kit contained the required supplies.

LPA is requesting the following documents be submitted to the Fresno CCL office by 04/03/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents (LIC9020A), Surety Bond.

No deficiencies issued. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Michelle Ligon, whose signature on this form confirms receipt of this document. This document was provided via email due to technical issues.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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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