<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209150
Report Date: 06/05/2023
Date Signed: 06/06/2023 09:03:02 AM

Document Has Been Signed on 06/06/2023 09:03 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:
06/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Supervisor, Amber MyersTIME COMPLETED:
03:55 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 06/05/2023, Licensing Program Analyst (LPA) Gorban and Licensing Program Manager (LPM) Chan conducted a case management in response to incident report occurred on 3/28/2023. LPA Gorban and LPM Chan met with facility supervisor Amber Myers stated the purpose of the visit and allowed entry into the facility. Administrator was notified but was not able to attend the visit.

LPA Gorban observed and interviewed residents in care, and reviewed facility files. LPA requested copies of facility files for department review including facility staff training by 6/7/23, 4pm pacific time.

No citations were issued during this visit.

Exit interview conducted. Report signed and provided to Supervisor Amber Myers for facility records.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023
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