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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208939
Report Date: 05/03/2023
Date Signed: 05/03/2023 01:28:47 PM


Document Has Been Signed on 05/03/2023 01:28 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 CARE IFACILITY NUMBER:
157208939
ADMINISTRATOR:LIGON, JOCELYNFACILITY TYPE:
740
ADDRESS:13400 INDURAN DRTELEPHONE:
(661) 679-6410
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 6DATE:
05/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Administrator, Michelle Ligon and Administrator Jocelyn LigonTIME COMPLETED:
01:10 PM
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On 05/03/2023, Licensing Program Analyst (LPA) A. Walton arrived at the facility unannounced to conduct an Annual Required Inspection. LPA introduced self, stated the purpose of the visit and was allowed to enter the facility. Facility staff contacted Administrators who 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 107.4 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 01/2023. All cleaning supplies are locked in cabinet. LPA reviewed staff and client records. Medications reviewed.\

LPA is requesting the following documents be submitted to the Fresno CCL office by 06/03/2023: 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 with Administrator. A copy of this report was discussed and left with Administrator, Michelle Ligon and Administrator Jocelyn Ligon. whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
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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