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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700634
Report Date: 06/20/2022
Date Signed: 06/20/2022 02:33:50 PM


Document Has Been Signed on 06/20/2022 02:33 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GOLDEN HILLS CARE HOME, INC.FACILITY NUMBER:
312700634
ADMINISTRATOR:DIZON, LISAFACILITY TYPE:
740
ADDRESS:1434 ELM STTELEPHONE:
(916) 474-4920
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 5DATE:
06/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lisa DizonTIME COMPLETED:
02:40 PM
NARRATIVE
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LPA Mknelly arrived to conduct a case management inspection for a change of ownership pre-licensing inspection. LPA followed department covid precautions, wore a surgical mask and was screened by facility.

Generally the home is clean and in good repair with resident needs being met.

LPA found staff training to be out of compliance.

Additionally, LPA advised that a new employee have a documented transfer, employee records set up and training be confirmed. LPA addressed concerns regarding a resident on hip restrictions and the use of bed rails. LPA advised that walkways be kept clear and gates swing freely. Lastly, LPA advised oxygen in use signs be posted.

As a result of this inspection a deficiency was noted.

Report reviewed, copy and appeal right provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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 2


Document Has Been Signed on 06/20/2022 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: GOLDEN HILLS CARE HOME, INC.
FACILITY NUMBER: 312700634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2022
Section Cited

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87411 Personnel Requirements - General.
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement was not met based on
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1 of 1 staff files reviewed and Licensee statement that staff training is not current.
This posed a potential risk to residents
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
LIC809 (FAS) - (06/04)
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