207209150-7-20-2023-24-AS-VGON-CTWP99-20230720110642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 207209150
Report Date: 07/19/2023
Date Signed: 07/20/2023 11:07:13 AM

Document Has Been Signed on 07/20/2023 11:07 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, THE		FACILITY NUMBER:	207209150
ADMINISTRATOR:	LUARES, BERNARDINO		FACILITY TYPE:	740
ADDRESS:	160 S 13TH STREET		TELEPHONE:	(707) 235-2717
CITY:	CHOWCHILLA	STATE: CA	ZIP CODE:	93610
CAPACITY:	41	CENSUS: 41	DATE:	07/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Elizabeth Prasad		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 07/19/23, Licensing Program Analyst (LPA) V Gorban arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPA was greeted by Administrator Elizabeth Prasad, stated the purpose of the visit and was allowed entry into the facility. Administrator on record is Elizabeth Prasad # 6058737740. Updated certificate will be replaced with old, once arrived. Administrator certificate is observed posted on the wall. LPA conducted a tour of the facility, inside and out. Facility temperature was 76 degrees F. Residents in care observed at the common area and others outside, at the time of visit. Facility is a 21 room facility double occupancy with bathroom in each room. Facility divided on sections for male and female residents in separate sections. Resident bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction / fire hazards. LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed. Bathrooms were toured and observed to have operational lights, running water, and non-obstructed floors. Hot water temperature tested at 117 degrees F. Trash can with lid and hand washing postings were observed. A supply of extra linens and towels were observed in the Hallway. Carbon monoxide and smoke detectors were tested and observed to be operational. Carbon Monoxide detectors were observed in hallways and common area. Fire Extinguisher was observed with a service date of 03/10/23. First aid kit was observed and contained all required items. Report continues on LIC 809C

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, THE	FACILITY NUMBER: 207209150
	VISIT DATE: 07/19/2023

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Medications were observed to be locked in a medication cart located in hallway. Cleaning supplies were observed to be in a locked cabinet. The exterior tour of back yard was conducted and found to be free from debris. A covered outdoor seating area was observed for residents in care. Side gate was self-closing and self-latching.

Resident files were reviewed and observed to have update emergency contact information, Admission agreement, and current medical assessment, Individual Performance Plans, Individual Behavioral Support Plans, and needs and service plans.

LPA reviewed Administrators personnel file and observed required health screening. Mandated Reporting requirements were provided and discussed with Administrator.

LPA requested the following documents at the time if visit: LIC 500, LIC 9020, LIC 610D, updated Administrator certificate, Disaster Plan (facility’s emergency plan procedures). LPA requested the following be submitted to Fresno CCL by 07/30/23

No deficiencies cited on today's visit.

An exit interview was conducted, and a copy of this report was discussed, signed, and provided to licensee.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (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

LIC809 (FAS) - (06/04)

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