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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700511
Report Date: 09/13/2023
Date Signed: 09/13/2023 03:34:08 PM


Document Has Been Signed on 09/13/2023 03:34 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:
09/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Oliver FuleTIME COMPLETED:
03:45 PM
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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.

During today's visit, LPA observed the presence of three (3) residents in the common areas. LPA was informed 3 other residents were resting in their rooms. No health, safety or personal rights violation observed.

LPA and Assistant Administrator discussed Administrator requirements. LPA informed Assistant Administrator the required documents to appoint a new Administrator needs to be submitted to LPA via email by Friday September 15, 2023 at 3 PM. LPA informed Assistant Administrator that if Licensee failed to do so may result to deficiencies cited in the future.

Exit interview conducted, and a copy of the report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
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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