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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317657
Report Date: 05/01/2024
Date Signed: 05/01/2024 10:31:46 AM


Document Has Been Signed on 05/01/2024 10:31 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GOLD HOME, THEFACILITY NUMBER:
340317657
ADMINISTRATOR:MARIUT, GINA & PETERFACILITY TYPE:
740
ADDRESS:6029 DAHBOY WAYTELEPHONE:
(916) 987-7368
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 5DATE:
05/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Co-administrator, Jennifer Kent TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/01/24 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Co-administrator, Jennifer Kent and explained the purpose of today's visit.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are five (5) bedrooms and two (2) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 114 degrees F in kitchen sink.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use. Facility was conducting quarterly fire and disaster drill as required.

LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed two (2) resident files and two (2) staff files and found all required paperwork. LPA reviewed medications for two (2) residents and observed no errors.

As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22.
Exit was interview conducted and copy of report given at the conclusion of this visit.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
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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