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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700511
Report Date: 03/19/2024
Date Signed: 03/19/2024 12:19:33 PM


Document Has Been Signed on 03/19/2024 12:19 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GOLDEN RETREAT SENIOR LIVING 2FACILITY NUMBER:
342700511
ADMINISTRATOR:FULE, OLIVERFACILITY TYPE:
740
ADDRESS:3431 PALESTINE LNTELEPHONE:
(916) 283-4257
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
03/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Russel Romero & Jero NinoblaTIME COMPLETED:
12:10 PM
NARRATIVE
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On 3/19/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit. LPA met with caregivers and explained the purpose of the visit. LPA then asked for caregivers to contact Administrator.

During this visit, LPA and Administrator discussed staffing concerns as LPA was informed former caregivers had resigned due to change of shift hours. LPA was informed there are two caregivers per shift for AM and PM, the one caregiver for NOC. LPA requested a copy of LIC 500 to thoroughly list what day each caregiver works.

Additionally, LPA observed S1 and S2 to not be associated to the facility. LPA was informed S1 and S2 has been in-training for two days. LPA had Administrator complete LIC 9182 CRIMINAL BACKGROUND CLEARANCE TRANSFER REQUEST for S1, S2 and S3. LPA then transferred S1, S2 and S3's clearance to facility roster and to their sister facility.

LPA and Administrator also discussed clearing the pathway next to the garage as it may be a fire concern as pathway is obstructed.

Please see LIC 809-D.

Exit interview and a copy of CCR 87411, report and appeal rights provided via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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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Document Has Been Signed on 03/19/2024 12:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GOLDEN RETREAT SENIOR LIVING 2
FACILITY NUMBER: 342700511

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2024
Section Cited
CCR
87411(g)(2)

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87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
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LPA obtained LIC 9182 for S1, S2, S3.

Licensee is to submit a statement of compliance of CCR 87411 to LPA Yang by 3/20/2024.
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Based on observation and file review, Licensee did not comply as LPA observed S1 and S2 to be working at the facility without a criminal clearance transfer which poses/posed an immediate health and safety risk to residents in care.
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Civil Penalty assessed as this is a repeat violation within 12 months.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
LIC809 (FAS) - (06/04)
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