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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209150
Report Date: 07/19/2023
Date Signed: 07/20/2023 11:09:10 AM


Document Has Been Signed on 07/20/2023 11:09 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:GOLDEN YEARS RESIDENTIAL CARE HOME, THEFACILITY NUMBER:
207209150
ADMINISTRATOR:LUARES, BERNARDINOFACILITY TYPE:
740
ADDRESS:160 S 13TH STREETTELEPHONE:
(707) 235-2717
CITY:CHOWCHILLASTATE: CAZIP CODE:
93610
CAPACITY:41CENSUS: 41DATE:
07/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator, Elizabeth PrasadTIME COMPLETED:
09:30 AM
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On 07/19/2023, Licensing Program Analyst (LPA) Gorban conducted a case management in response to incident report occurred on 5/16/2023.

LPA Gorban met with facility staff stated the purpose of the visit and allowed entry into the facility. Administrator was notified and arrived later.

LPA Gorban observed and interviewed resident (R1) in care and reviewed R1’s facility files.

Resident currently resides in the facility and. R1’s personal file is updated on 11/23/22

No citations were issued during this visit.

Exit interview conducted. Report signed and provided to Administrator Elizabeth Prasad for facility records.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
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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