207209150-5-24-2024-24-AS-VGON-D5L28V-20240524171058

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 207209150
Report Date: 05/24/2024
Date Signed: 05/24/2024 05:11:23 PM

Document Has Been Signed on 05/24/2024 05:11 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
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: 39	DATE:	05/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, Amber Myers		TIME COMPLETED:	01:45 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 04/03/2024, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Administrator (AD), Amber Myers, certification number 6066713740 and expiration date 10/10/2025. LPA conducted tour of facility with AD. Residents were observed at the facility after breakfast and in common areas. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguishers were observed with a service date of 03/20/2024. Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Food is delivered twice a week by staff. Refrigerator temperature was maintained at 30 degree F. and freezer was maintained at 0 degree F. LPA toured a sample of resident bedrooms. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at 105 degrees F. LPA observed securely fastened grab bars and non-skid mat in all shower areas. Medications were stored in a locked medication room in a medication cart. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. LPA toured laundry room door was locked and accessible to staff only. LPA observed chemicals were stored and locked. Report continues on LIC809-C

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

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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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: 05/24/2024

NARRATIVE

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Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents.

Residents’ file was reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. Also LPA reviewed staff files. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record, and staff training . Staff are fingerprinted clear and associated to the facility.

LPA requested the following records:

· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 05/30/2024

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

An exit interview was conducted with AD. Report was signed and with appeal rights provided to AD for facility records.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

LIC809 (FAS) - (06/04)

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