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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317657
Report Date: 04/17/2023
Date Signed: 04/17/2023 03:58:15 PM


Document Has Been Signed on 04/17/2023 03:58 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: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:
04/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Administrator, Gina Mariut TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPAs) Lavinia Muscan and Talwinder Bains arrived on Monday April 17, 2023 to conduct the annual inspection. LPAs met with Administrator, Gina Mariut and explained the purpose of the visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (5) and staff files (3). All resident files contained the required paperwork. All staff files contained the required paperwork. All staff have current first aid and CPR training. Facility was clean and well organized. Facility is current on fire drills. All required posting were observed. Staff training contained the required initial training.

LPAs and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. The disaster drill is current. There is a side gate for emergency access. LPAs checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPAs observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPAs observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use. Water temperature is within compliance. In the areas toured, there were no health or safety violations observed.

LPAs requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 04/30/23.

Exit interview conducted. A copy of this report was printed and given to Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
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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