<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700511
Report Date: 06/20/2023
Date Signed: 06/20/2023 05:44:58 PM


Document Has Been Signed on 06/20/2023 05:44 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:HOLMQUIST, TRAVIS CFACILITY TYPE:
740
ADDRESS:3431 PALESTINE LNTELEPHONE:
(916) 283-4257
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
06/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Oliver FuleTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/20/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit. LPA met with Assistant Administrator (AA), Oliver Fule, and explained the purpose of the visit. LPA ensure to apply hand sanitizer and wore the following Personal Protective Equipment: surgical mask.

LPA observed the presence of five (5) residents in the facility, one (1) resident was out of the community. The facility currently has two (2) residents on hospice services.

During today's visit, LPA and AA conducted a tour of the interior of the facility to ensure the health and safety of residents in care. In areas toured included but not limited to: common areas, kitchen, residents bedrooms, and bathroom.

LPA discussed the importance of criminal background clearance prior to employment. LPA provided AA the copy of Title 22, California Code Regulation 87411. LPA informed AA transfer requests can be faxed in to Licensing, requirement of LIC 9182, LIC 508 and a copy of individual's identification card.

As a result of today's visit, deficiency was cited. Please see attached LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/20/2023 05:44 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: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2023
Section Cited
CCR
87411(g)(2)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
-Licensee will transfer S1's criminal clearance to the facility via Guardian or submit a transfer request to CCLD.
-Licensee is to submit a statement of compliance of CCR 87411 to LPA Yang by close of business 6/21/2023.
-S1 is to not be at the facility until clearance has been transferred and associated.
8
9
10
11
12
13
14
Based on interview, Licensee did not comply as Licensee informed LPA S1 "wanted to get involved on a physical aspect of being there from time to time" which poses/posed an immediate health, safety or personal rights risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2