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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700511
Report Date: 02/28/2023
Date Signed: 02/28/2023 05:53:42 PM


Document Has Been Signed on 02/28/2023 05:53 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 RETREAT SENIOR LIVING 2FACILITY NUMBER:
342700511
ADMINISTRATOR:HOLMQUIST, TRAVIS CFACILITY TYPE:
740
ADDRESS:3431 PALESTINE LNTELEPHONE:
(916) 283-4257
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
02/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Yoda RhondaTIME COMPLETED:
06:10 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Caregiver, Yoda Rhonda, and explained the purpose of the visit. LPA spoke with Administrator over the phone, who informed LPA he was unable to arrive to the facility at this time. Administrator informed LPA inspection can be conducted with Caregiver.

LPA and Caregiver toured the interior of the facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathrooms, and kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Caregiver completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA observed PPE's to be posted throughout the facility. Caregiver informed LPA the facility is strict on masking. Caregiver emphasized that Administrator informs all staff and visitors that mask is mandated at the facility.

At this time, LPA requested for Licensee to submit the following requested documents to LPA by 03/6/2023:
  • LIC 308 Designation of Administrative Responsibility
  • Administrator Certificate
  • Current Liability Insurance
  • LIC 500 Personnel Report

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report was emailed to Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
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)
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