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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700989
Report Date: 04/24/2024
Date Signed: 04/24/2024 10:07:13 AM


Document Has Been Signed on 04/24/2024 10:07 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:GOLDEN LIVING HOME CAREFACILITY NUMBER:
312700989
ADMINISTRATOR:SALVA, LITAFACILITY TYPE:
740
ADDRESS:1415 LONG CREEK WAYTELEPHONE:
(916) 772-6224
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 5DATE:
04/24/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Lita Salva, AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a POC visit. LPA met with Administrator Lita Salva during today's inspection. Currently there are 5 residents at the facility.

LPA reviewed all plan of corrections with Administrator. LPA was able to clear all deficiencies except one. Administrator to send to LPA all 9 pages of the 610E form by 4/25/24. Letter of clearance provided to Administrator.

Exit interview conducted. Copy of report provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
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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