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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002894
Report Date: 06/20/2022
Date Signed: 06/20/2022 02:13:47 PM


Document Has Been Signed on 06/20/2022 02:13 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 HOMEFACILITY NUMBER:
315002894
ADMINISTRATOR:MAHAJAN, VIVEKFACILITY TYPE:
740
ADDRESS:1434 ELM STREETTELEPHONE:
(916) 474-4920
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 5DATE:
06/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Vivek MajajanTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility announced on 6/20/22 to conduct a Pre-licensing referencing the infection control domain. LPA met with licensee and applicant and explained the purpose of the visit. Prior to initiating the pre-licensing inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical Mask.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and Vivek completed the infection control recommendations and facility was found to be in substantial compliance at this time.

Component III review completed.

Facility is in significant compliance
License pending approval.

Exit interview conducted and copy of report left at the facility.
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)
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