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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700511
Report Date: 02/16/2024
Date Signed: 02/16/2024 04:16:29 PM


Document Has Been Signed on 02/16/2024 04:16 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: 2DATE:
02/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Oliver FuleTIME COMPLETED:
03:21 PM
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On 2/16/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection. LPA met with Administrator, Oliver Fule, and explained the purpose of the visit.

Today's inspection, LPA observed one resident resting in her private room, another resident in the common areas. LPA was informed the third resident was transported to the hospital for evaluation.

LPA and Administrator conducted a tour of the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: six residents bedrooms, two bathrooms, garage, kitchen, and the common areas.

LPA observed facility to have the mandated posters posted at entrance. LPA observed an active Administrator Certificate posted with facility license. LPA observed medications, sharps, toxins to be locked and inaccessible to residents in care. LPA observed 2+ days of perishable and 7+ days on nonperishable foods. LPA observed hot water temperature at maximum to be 115*. LPA observed facility to be clean, sanitary and free of hazardous obstruction. LPA conducted file reviews for three residents in care and three staff.

At this time, LPA is requesting copy of facility liability insurance to be emailed to LPA by Friday February 23, 2023

LPA and Administrator discussed the outstanding licensing fee from 2023 to current. LPA and Administrator completed the CARE tool and deficiencies was observed. Please see LIC809-D.

Exit interview conducted and a copy of the report and appeal rights will be emailed to Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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 02/16/2024 04:16 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: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.185(b)(1)(F)
ยง1569.185 Fees for license or applications; use of revenues; collected; denial or forfeiture
(b) (1) In addition to fees set forth in subdivision (a), the department shall charge all of the following fees:
(F) A late fee that represents an additional 50 percent of the established current annual fee when a licensee fails to pay the current annual licensing fee on or before the due date as indicated by postmark on the payment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as LPA observed outstanding balance of $1,237 due to the unpaid 2023 fee plus late fee assessed, which poses a potential health and safety risk for residents in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee is to pay off the outstanding fee and submit proof of payment to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
LIC809 (FAS) - (06/04)
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