<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
315002894
Report Date:
02/28/2023
Date Signed:
02/28/2023 02:36:32 PM
Document Has Been Signed on
02/28/2023 02:36 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
CHICO - RESIDENTIAL
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
GOLDEN HILLS CARE HOME
FACILITY NUMBER:
315002894
ADMINISTRATOR:
MAHAJAN, VIVEK
FACILITY TYPE:
740
ADDRESS:
1434 ELM STREET
TELEPHONE:
(916) 474-4920
CITY:
ROSEVILLE
STATE:
CA
ZIP CODE:
95678
CAPACITY:
6
CENSUS:
4
DATE:
02/28/2023
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
12:36 PM
MET WITH:
Vivek Mahajan, Administrator
TIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Administrator Vivel Mahajan during today's inspection. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks.
LPA arrived to facility to discuss incident report that was sent into CCL by Administrator. Incident report indicates R1 was sent out to the hospital due to R1's wound being staged a stage 3. Homehealth was following resident and recommended R1 to be transported to a higher level of care. Administrator set R1 out to the hospital that afternoon. LPA requested several documents related to R1.
No deficiencies are being cited as a result of todays inspection.
Exit interview conducted.
SUPERVISOR'S NAME:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Bethany Mirlohi
TELEPHONE:
(916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE:
02/28/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/28/2023
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
1