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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208939
Report Date: 05/14/2022
Date Signed: 05/14/2022 10:00:38 AM


Document Has Been Signed on 05/14/2022 10:00 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 HEART FAMILY CARE IFACILITY NUMBER:
157208939
ADMINISTRATOR:LIGON, JOCELYNFACILITY TYPE:
740
ADDRESS:13400 INDURAN DRTELEPHONE:
(661) 679-6410
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 5DATE:
05/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Licensee Michelle LigonTIME COMPLETED:
10:15 AM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Infection Inspection on this date. LPA was met by Staff Leonora Pangilinan 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 unlocked in laundry room. LPA observed the following personal protective equipment in a storage cabinet ; gloves, face shields, hand sanitizer and masks. Facility did not have training records for infection control training but conducted training and will submit documentation. LPA observed all facility staff to be wearing masks upon arrival.

Resident’s files have updated emergency contact information.

See 809D for deficiency.

Exit interview was conducted and a copy of this report and appeal rights were provided
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2022
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 1



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 I
FACILITY NUMBER: 157208939

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above by having cleaning supplies not locked on the floor in laundry room and accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2022
Plan of Correction
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Plan of Correction POC Licensee agrees to lock cleaning supplies making the supplies inaccessible to residents in care. POC was cleared during visit.
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) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2022
LIC809 (FAS) - (06/04)
Page: 1 of 1