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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700989
Report Date: 08/14/2024
Date Signed: 08/14/2024 12:41:34 PM

Document Has Been Signed on 08/14/2024 12:41 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:GOLDEN LIVING HOME CAREFACILITY NUMBER:
312700989
ADMINISTRATOR/
DIRECTOR:		SALVA, LITAFACILITY TYPE:
740
ADDRESS:1415 LONG CREEK WAYTELEPHONE:
(916) 772-6224
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 5DATE:
08/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Lita Salva, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi and Graham arrived unannounced to conduct a case management visit. LPA met with administrator Lita Salva during today's inspection.
During today's inspection LPA's toured the facility, reviewed 5 of 5 resident records, and reviewed 2 staff records. In addition, LPA reviewed 5 of 5 resident medications reviewing with doctor orders. During today's inspection LPA cited on the following deficiencies:
  1. LPA's observed the front door locked from the inside, and the fire exits on the side of the house both had a lock present. Carbon monoxide detector was observed without batteries.
  2. S1 has fingerprint clearance but was not associated to the facility and did not have a complete staff file.
  3. LPA observed the pantry storing food is locked during the night hours.
  4. Facility staff are sleeping in the common living room during night hours.
  5. R1 has a diagnosis of dementia and has an LIC602 dated for 1/3/22.
  6. R2 was observed with a bottle and a small cup of pills next to her, and according to her LIC602 resident is unable to manage medications. Medications were observed in R2's bedroom unlocked.
  7. LPA observed several residents had missing orders or medications.

Deficiencies are cited on 809-D. Civil penalties assessed.

Copy of report provided and appeal rights given.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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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Document Has Been Signed on 08/14/2024 12:41 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 08/14/2024 at 11:04 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN LIVING HOME CARE
FACILITY NUMBER: 312700989

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2024
Section Cited

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All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal
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This requirement is not met as evidenced by: Based on observation and interview the license did not keep fire exits clear which poses an immediate health and safety risk to residents in care.
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Statement to be sent into CCL by 8/15/24. Administrator agrees to out in new batteries for the carbon monoxide detector.
Type A
08/23/2024
Section Cited

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87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
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This requirement is not met as evidenced by: Based on observation licensee did not have all medications or orders available to clients which poses an immediate health and safety risk to residents in care.
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2024 12:41 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 08/14/2024 at 11:32 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN LIVING HOME CARE
FACILITY NUMBER: 312700989

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2024
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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This requirement is not met as evidenced by: Based on record review the licensee did not have S1 associated to the facility prior to working at the home which poses a potential health and safety risk to residents in care.
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Type B
08/23/2024
Section Cited

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87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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This requirement is not met as evidenced by: Based on observation and interview licensee kept food cabinet locked at night which poses a potential health and safety risk to residents in care.
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


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Document Has Been Signed on 08/14/2024 12:41 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 08/14/2024 at 11:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN LIVING HOME CARE
FACILITY NUMBER: 312700989

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2024
Section Cited

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87307 Personal Accommodations and Services. (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.
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This requirement is not met as evidenced by: Based on observation staff are sleeping in the common living room which poses potential health and safety risk to residents in care.
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facility unassisted. LIC500 to be sent into CCL by 8/23/24.
Type B
08/30/2024
Section Cited

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(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
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This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 1 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


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Document Has Been Signed on 08/14/2024 12:41 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 08/14/2024 at 12:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN LIVING HOME CARE
FACILITY NUMBER: 312700989

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2024
Section Cited

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(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above and LPA observed medications unlocked in the R2 bedroom and outside which poses an immediate health, safety or personal rights risk to persons in care.
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by 8/30/24.

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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:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
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