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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700512
Report Date: 08/19/2021
Date Signed: 08/19/2021 04:59:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GOLDEN RETREAT SENIOR LIVING 1FACILITY NUMBER:
342700512
ADMINISTRATOR:HOLMQUIST, TRAVIS CFACILITY TYPE:
740
ADDRESS:3425 PALESTINE LNTELEPHONE:
(916) 482-5507
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Oliver Fule, Administrator and Gloria Farrow, caregiver TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA spoke to Oliver Fule, Administrator, and explained purpose of inspection. Administrator was wearing a mask. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical Mask. LPA observed (5) residents to be in their rooms either sleeping or watching television.

LPA and Administrator toured and observed the facility to ensure the health and safety of residents in care. Areas toured include, but are not limited to: common areas, (6) private bedrooms, (3) bathrooms, dining room and kitchen. LPA observed 2+day perishable and 7+day non-perishable food supply. PPE supplies for 30 days on hand. In the areas toured, there were no immediate health, safety, or personal rights violations observed. LPA and Administrator completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 72* F.

LPA requested updated copy of LIC500, LIC610E and liability insurance be faxed to the department by 8/26/2021. Discussed current testing requirements.

There are no deficiencies cited during today's inspection.

Exit interview. Copy of report provided to caregiver.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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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