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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209150
Report Date: 05/19/2022
Date Signed: 05/19/2022 12:49:40 PM


Document Has Been Signed on 05/19/2022 12:49 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: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: 38DATE:
05/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Elizabeth Prasad, DirectorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. Administrator Bernardino Luares was unavailable, however, designated Director Elizabeth Prasad. LPA met with the Director and Christine Mason, Supervisor and stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in was observed upon entry. Facility has one entrance/exit point.

Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trashcans. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and beds are six feet apart. The exterior tour was conducted.

LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information.

Based on today’s inspection, deficiencies were cited in the areas evaluated and listed on the LIC809D according to California Code of Regulations Title 22.

Exit interview was conducted.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
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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Document Has Been Signed on 05/24/2022 11:08 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/20/2022 11:27 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: GOLDEN YEARS RESIDENTIAL CARE HOME, THE
FACILITY NUMBER: 207209150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA observed mold in the male communal shower. LPA observed two sofas in common areas cushions and fabric were ripped and in bad condition. LPA observed the facility's roof drip edge deteriorating. LPA observed several unused furniture, mattresses, chairs, cabinets and refrigerator in the back-parking lot of the facility, which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Licensee shall remove all items from the back-parking lot and removed the mold from the male communal shower and will submit photos to CCLD on 05/27/2022. Licensee will repair or replace two sofas for the common area and the facility's roof drip edge by 06/03/2022.
Type B
Section Cited
CCR
87412(a)(2)
87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (2) Health screening documents as specified in Section 87411(f).
This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited. Licensee was uable to provide record of Health Screening for a total of five (5) staff Health Screening forms at the time of the inspection, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Licensee shall submit Health Screening documents for the five staff by 05/27/2022 to CCLD. Licensee shall a submit a written plan of how to maintain personnel records by 05/27/2022.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: GOLDEN YEARS RESIDENTIAL CARE HOME, THE
FACILITY NUMBER: 207209150
VISIT DATE: 05/19/2022
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Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· 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: 5/27/2022

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.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC809 (FAS) - (06/04)
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