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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700511
Report Date: 06/09/2023
Date Signed: 06/09/2023 01:43:12 PM


Document Has Been Signed on 06/09/2023 01:43 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: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:
06/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Oliver Fule and Karen LimTIME COMPLETED:
02:00 PM
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On 06/09/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding some concerns facility had. LPA met with Administrator (Admin), Oliver Fule, and caregiver, Karen Lim (KL), and explained the purpose of the visit. The facility is currently in the process of Change of Ownership with applicant, Karen Lim.

LPA was informed of some concerns regarding medical services for residents in care. LPA informed Admin and KL that facility is to follow Plan of Operation regardless of resident family's request. LPA emphasized facility is to contact medical services in events which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. LPA reminded Admin and KL in any suspicions of abuse, facility is to submit a SOC 341 to Long Term Care Ombudsman and Licensing. Additionally, LPA informed Admin and KL of reporting requirements in California Code Regulation 87211.

Exit interview conducted with Admin and a copy of the report was left at the facility.


SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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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